Healthcare Provider Details

I. General information

NPI: 1376518670
Provider Name (Legal Business Name): GARY S FIALK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 12/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 TOWN CENTER DR SUITE 180
RESTON VA
20190-5896
US

IV. Provider business mailing address

10301 DEMOCRACY LN SUITE 410
FAIRFAX VA
22030-2545
US

V. Phone/Fax

Practice location:
  • Phone: 703-689-3311
  • Fax: 703-435-0137
Mailing address:
  • Phone: 703-876-5942
  • Fax: 703-876-5972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number0101053797
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number010153797
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: