Healthcare Provider Details

I. General information

NPI: 1790815645
Provider Name (Legal Business Name): THE NATIONAL SPORTS MEDICINE INSTITUTE,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 09/23/2020
Certification Date: 09/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19455 DEERFIELD AVE SUITE 312
LANSDOWNE VA
20176-8102
US

IV. Provider business mailing address

19455 DEERFIELD AVE SUITE 312
LANSDOWNE VA
20176-8102
US

V. Phone/Fax

Practice location:
  • Phone: 703-729-5010
  • Fax: 703-729-5833
Mailing address:
  • Phone: 703-729-5010
  • Fax: 703-729-5833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DAVID CHARLES JOHNSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 703-729-5010