Healthcare Provider Details

I. General information

NPI: 1598776817
Provider Name (Legal Business Name): PROFESSIONAL DERMATOLOGY CARE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 01/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 ROBERT FULTON DR SUITE 520
RESTON VA
20191-5461
US

IV. Provider business mailing address

1801 ROBERT FULTON DR SUITE 520
RESTON VA
20191-5461
US

V. Phone/Fax

Practice location:
  • Phone: 703-860-1818
  • Fax: 703-860-5303
Mailing address:
  • Phone: 703-860-1818
  • Fax: 703-860-5303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0101232644
License Number StateVA

VIII. Authorized Official

Name: DR. MAITHILY NANDEDKAR
Title or Position: OWNER
Credential: M.D.
Phone: 703-860-1818