Healthcare Provider Details

I. General information

NPI: 1508901844
Provider Name (Legal Business Name): ROBERTA LEE GARTSIDE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 TOWN CENTER DR SUITE 412
RESTON VA
20190-3215
US

IV. Provider business mailing address

1800 TOWN CENTER DR SUITE 412
RESTON VA
20190-3215
US

V. Phone/Fax

Practice location:
  • Phone: 703-742-8004
  • Fax: 703-742-3749
Mailing address:
  • Phone: 703-742-8004
  • Fax: 703-742-3749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number0101042741
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: