Healthcare Provider Details

I. General information

NPI: 1669403051
Provider Name (Legal Business Name): INTERNAL MEDICINE PRACTICE ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 10/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46090 LAKE CENTER PLZ 201
POTOMAC FALLS VA
20165-5876
US

IV. Provider business mailing address

46090 LAKE CENTER PLZ 201
POTOMAC FALLS VA
20165-5876
US

V. Phone/Fax

Practice location:
  • Phone: 703-444-6544
  • Fax: 703-444-1121
Mailing address:
  • Phone: 703-444-6544
  • Fax: 703-444-1121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101236706
License Number StateVA

VIII. Authorized Official

Name: DR. ALOK RUSTOGI
Title or Position: DIRECTOR
Credential: MD
Phone: 703-880-5539