Healthcare Provider Details

I. General information

NPI: 1598787756
Provider Name (Legal Business Name): KURT LAURENCE MAGGIO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 08/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7512 GARDNER PARK DR
GAINESVILLE VA
20155-3414
US

IV. Provider business mailing address

1611 8TH PL
MCLEAN VA
22101-4615
US

V. Phone/Fax

Practice location:
  • Phone: 703-753-9860
  • Fax: 703-753-9863
Mailing address:
  • Phone: 571-366-0456
  • Fax: 703-753-9863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number0101058908
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number0101058908
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number0101058908
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: