Healthcare Provider Details

I. General information

NPI: 1053407452
Provider Name (Legal Business Name): THERESA CONOLOGUE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 04/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 SAM PERRY BLVD STE 121
FREDERICKSBURG VA
22401-4465
US

IV. Provider business mailing address

1101 SAM PERRY BLVD STE 121
FREDERICKSBURG VA
22401-4465
US

V. Phone/Fax

Practice location:
  • Phone: 540-899-1600
  • Fax:
Mailing address:
  • Phone: 540-899-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number0102201892
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: