Healthcare Provider Details

I. General information

NPI: 1679804900
Provider Name (Legal Business Name): DOMINION UROLOGICAL CONSULTANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2010
Last Update Date: 01/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8503 ARLINGTON BOULEVARD #310
FAIRFAX VA
22031
US

IV. Provider business mailing address

8503 ARLINGTON BOULEVARD #310
FAIRFAX VA
22031
US

V. Phone/Fax

Practice location:
  • Phone: 703-208-4200
  • Fax: 703-876-1799
Mailing address:
  • Phone: 703-208-4200
  • Fax: 703-876-1799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: SIMON CHUNG
Title or Position: MANAGING PHYSICIAN
Credential: M.D.
Phone: 703-208-4200