Healthcare Provider Details

I. General information

NPI: 1316986664
Provider Name (Legal Business Name): JOHN ALEXANDER SIEDLECKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3742 WINTERFIELD RD
MIDLOTHIAN VA
23113-9238
US

IV. Provider business mailing address

3742 WINTERFIELD RD
MIDLOTHIAN VA
23113-9230
US

V. Phone/Fax

Practice location:
  • Phone: 804-330-3335
  • Fax: 804-330-9205
Mailing address:
  • Phone: 804-330-3335
  • Fax: 804-330-9205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101054432
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: