Healthcare Provider Details

I. General information

NPI: 1598823718
Provider Name (Legal Business Name): SUZANNE KIM DOUD GALLI M.D., PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 TOWN CENTER DR SUITE 260
RESTON VA
20190-5896
US

IV. Provider business mailing address

1860 TOWN CENTER DR SUITE 260
RESTON VA
20190-5896
US

V. Phone/Fax

Practice location:
  • Phone: 703-787-0199
  • Fax: 703-787-0530
Mailing address:
  • Phone: 703-787-0199
  • Fax: 703-787-0530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number0101235229
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: