Healthcare Provider Details

I. General information

NPI: 1336386309
Provider Name (Legal Business Name): ILYA ZAVELSKY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2009
Last Update Date: 08/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11127 JOURNAL PKWY STE 101
KING GEORGE VA
22485-3468
US

IV. Provider business mailing address

12206 HUNTERS GLEN CT
GLEN ALLEN VA
23059-6968
US

V. Phone/Fax

Practice location:
  • Phone: 540-775-6891
  • Fax: 540-775-6894
Mailing address:
  • Phone: 804-364-2727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101054332
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: