Healthcare Provider Details

I. General information

NPI: 1386006484
Provider Name (Legal Business Name): SIARHEI LIAUCHONAK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2016
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 GALLOWS RD
FALLS CHURCH VA
22042-3307
US

IV. Provider business mailing address

8252 TOWNSEND ST #202
FAIRFAX VA
22031-4852
US

V. Phone/Fax

Practice location:
  • Phone: 571-314-3530
  • Fax:
Mailing address:
  • Phone: 571-314-3530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101277274
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number0101277274
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: