Healthcare Provider Details

I. General information

NPI: 1568553386
Provider Name (Legal Business Name): EDNA REYES BALDO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8136 OLD KEENE MILL RD
SPRINGFIELD VA
22152
US

IV. Provider business mailing address

6857 COMPTON HTS CIR
CLIFTON VA
20124
US

V. Phone/Fax

Practice location:
  • Phone: 703-569-1031
  • Fax: 703-455-1725
Mailing address:
  • Phone: 703-815-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number0101035039
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: