Healthcare Provider Details

I. General information

NPI: 1750342333
Provider Name (Legal Business Name): STEPHEN G. HARRISON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 TOWN CENTER DR SUITE # 205
RESTON VA
20190-3292
US

IV. Provider business mailing address

10691 ALLIWELLS CT
OAKTON VA
22124-1771
US

V. Phone/Fax

Practice location:
  • Phone: 703-435-3636
  • Fax: 703-435-9145
Mailing address:
  • Phone: 703-435-3636
  • Fax: 703-435-9145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101028882
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: