Healthcare Provider Details

I. General information

NPI: 1184731796
Provider Name (Legal Business Name): LOUDOUN MEDICAL GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 07/31/2020
Certification Date: 07/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7430 HERITAGE VILLAGE PLAZA SUITE 101
GAINESVILLE VA
20155
US

IV. Provider business mailing address

7430 HERITAGE VILLAGE PLZ SUITE 101
GAINESVILLE VA
20155-3088
US

V. Phone/Fax

Practice location:
  • Phone: 703-753-3338
  • Fax: 703-753-7870
Mailing address:
  • Phone: 703-753-3338
  • Fax: 703-753-7870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: MUKESH D. BHAKTA
Title or Position: PRESIDENT
Credential: DPM
Phone: 703-753-3338