Healthcare Provider Details

I. General information

NPI: 1144961921
Provider Name (Legal Business Name): CAMPBELL RYAN HATHAWAY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 06/22/2025
Certification Date: 06/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 DEWITT LOOP
FORT BELVOIR VA
22060-5285
US

IV. Provider business mailing address

9300 DEWITT LOOP
FORT BELVOIR VA
22060-5285
US

V. Phone/Fax

Practice location:
  • Phone: 571-231-1803
  • Fax:
Mailing address:
  • Phone: 210-916-0439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101281743
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: