Healthcare Provider Details

I. General information

NPI: 1629097092
Provider Name (Legal Business Name): LAURENCE SEIDMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6120 BRANDON AVE SUITE 308
SPRINGFIELD VA
22150-2522
US

IV. Provider business mailing address

6120 BRANDON AVE SUITE 308
SPRINGFIELD VA
22150-2522
US

V. Phone/Fax

Practice location:
  • Phone: 703-451-3333
  • Fax: 703-451-7219
Mailing address:
  • Phone: 703-451-3333
  • Fax: 703-451-7219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101042992
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: