Healthcare Provider Details

I. General information

NPI: 1043577190
Provider Name (Legal Business Name): SAMITA SALLY GOYAL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2012
Last Update Date: 11/15/2023
Certification Date: 11/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3960 STILLMAN PKWY
GLEN ALLEN VA
23060-4197
US

IV. Provider business mailing address

6500 MILLER DR
ALEXANDRIA VA
22315-3528
US

V. Phone/Fax

Practice location:
  • Phone: 804-270-3333
  • Fax:
Mailing address:
  • Phone: 703-626-6165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number61439
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number0101266133
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: