Healthcare Provider Details

I. General information

NPI: 1386255602
Provider Name (Legal Business Name): LOUDOUN MEDICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2020
Last Update Date: 08/18/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7430 HERITAGE VILLAGE PLZ UNIT 101
GAINESVILLE VA
20155-3089
US

IV. Provider business mailing address

224D CORNWALL ST NW STE 403
LEESBURG VA
20176-2704
US

V. Phone/Fax

Practice location:
  • Phone: 703-753-3338
  • Fax:
Mailing address:
  • Phone: 703-737-6012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: HEATHER STANTON
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 703-737-6012