Healthcare Provider Details

I. General information

NPI: 1659759025
Provider Name (Legal Business Name): NORTHERN VIRGINIA OTOLARYNGOLOGY ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2015
Last Update Date: 06/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8452 RENALDS AVE
MARSHALL VA
20115-3755
US

IV. Provider business mailing address

8452 RENALDS AVE
MARSHALL VA
20115-3755
US

V. Phone/Fax

Practice location:
  • Phone: 571-354-6595
  • Fax: 540-227-6543
Mailing address:
  • Phone: 571-354-6595
  • Fax: 540-227-6543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0788506-4
License Number StateVA

VIII. Authorized Official

Name: JAIRO I TORRES
Title or Position: OTOLARYNGOLOGY
Credential: MD
Phone: 571-354-6595