Healthcare Provider Details

I. General information

NPI: 1679656607
Provider Name (Legal Business Name): DORENE ANNE O'HARA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 09/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1734 SEAGULL CT APT. 402
RESTON VA
20194-4307
US

IV. Provider business mailing address

1734 SEAGULL CT APT. 402
RESTON VA
20194-4307
US

V. Phone/Fax

Practice location:
  • Phone: 732-423-8533
  • Fax: 571-313-0523
Mailing address:
  • Phone: 732-423-8533
  • Fax: 571-313-0523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number048518
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number0101240686
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: