Healthcare Provider Details

I. General information

NPI: 1083994271
Provider Name (Legal Business Name): ANDREW LEONARD KOCHUBA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2011
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 SAMUEL MORSE DR
RESTON VA
20190-5317
US

IV. Provider business mailing address

1825 SAMUEL MORSE DR
RESTON VA
20190-5317
US

V. Phone/Fax

Practice location:
  • Phone: 703-893-6168
  • Fax:
Mailing address:
  • Phone: 703-893-6168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberMD210002211
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberD0093948
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number2018-02093
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number0101274320
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: