Healthcare Provider Details

I. General information

NPI: 1851889158
Provider Name (Legal Business Name): RICHARD JAMES EDGAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2018
Last Update Date: 10/21/2022
Certification Date: 10/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 TOWN CENTER PKWY STE 459
RESTON VA
20190-3300
US

IV. Provider business mailing address

2445 ARMY NAVY DR FL 4
ARLINGTON VA
22206-2988
US

V. Phone/Fax

Practice location:
  • Phone: 703-892-6500
  • Fax: 703-769-8437
Mailing address:
  • Phone: 703-892-6500
  • Fax: 703-769-8437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberD0094921
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD473773
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number0101275769
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: