Healthcare Provider Details

I. General information

NPI: 1528095809
Provider Name (Legal Business Name): DIABETES AND THYROID ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10711 SPOTSYLVANIA AVE
FREDERICKSBURG VA
22408-2674
US

IV. Provider business mailing address

10711 SPOTSYLVANIA AVE
FREDERICKSBURG VA
22408-2674
US

V. Phone/Fax

Practice location:
  • Phone: 540-891-8499
  • Fax: 540-891-8662
Mailing address:
  • Phone: 540-891-8499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARK ALLEN MCCLANAHAN
Title or Position: PRESIDENT
Credential: MD
Phone: 540-891-8499