Healthcare Provider Details

I. General information

NPI: 1861579898
Provider Name (Legal Business Name): KIMBERLY ANN MATZIE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 09/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 PROSPERITY AVE SUITE 200
FAIRFAX VA
22031-4357
US

IV. Provider business mailing address

2710 PROSPERITY AVE SUITE 200
FAIRFAX VA
22031-4357
US

V. Phone/Fax

Practice location:
  • Phone: 703-280-2841
  • Fax: 703-280-4773
Mailing address:
  • Phone: 703-280-2841
  • Fax: 703-280-4773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number0101248220
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number224443
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: