Healthcare Provider Details

I. General information

NPI: 1760499669
Provider Name (Legal Business Name): MARK T STEVENS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 12/17/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10706 WYNKOOP DR
GREAT FALLS VA
22066-1606
US

IV. Provider business mailing address

10706 WYNKOOP DR
GREAT FALLS VA
22066-1606
US

V. Phone/Fax

Practice location:
  • Phone: 703-282-9468
  • Fax:
Mailing address:
  • Phone: 703-282-9468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number0101257868
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: