Healthcare Provider Details

I. General information

NPI: 1962997825
Provider Name (Legal Business Name): SYDNEY BEACHE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2018
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 PROSPERITY AVE STE 200
FAIRFAX VA
22031-4358
US

IV. Provider business mailing address

2710 PROSPERITY AVE STE 200
FAIRFAX VA
22031-4358
US

V. Phone/Fax

Practice location:
  • Phone: 443-717-0961
  • Fax:
Mailing address:
  • Phone: 443-717-0961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number0101290498
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: