Healthcare Provider Details

I. General information

NPI: 1336944321
Provider Name (Legal Business Name): JEEVAN ERRABOLU MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2025
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11130 SUNRISE VALLEY DR STE 120
RESTON VA
20191-5474
US

IV. Provider business mailing address

11130 SUNRISE VALLEY DR STE 120
RESTON VA
20191-5474
US

V. Phone/Fax

Practice location:
  • Phone: 571-376-1135
  • Fax:
Mailing address:
  • Phone: 571-376-1135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRIS KIRBY
Title or Position: CREDENTIALING ADMINISTRATOR
Credential:
Phone: 301-565-2250