Healthcare Provider Details

I. General information

NPI: 1811008857
Provider Name (Legal Business Name): GORDON H HAFNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 11/16/2022
Certification Date: 11/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8260 WILLOW OAKS CORPORATE DR STE 600
FAIRFAX VA
22031-4528
US

IV. Provider business mailing address

PO BOX 37174
BALTIMORE MD
21297-3174
US

V. Phone/Fax

Practice location:
  • Phone: 571-472-4670
  • Fax: 571-665-6798
Mailing address:
  • Phone: 571-423-5699
  • Fax: 571-423-5698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101037279
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: