Healthcare Provider Details

I. General information

NPI: 1609074459
Provider Name (Legal Business Name): ENDOCRINOLOGY AND INFECTIOUS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 08/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21475 RIDGETOP CIR STE 350
STERLING VA
20166-6580
US

IV. Provider business mailing address

6035 BURKE CENTRE PKWY
BURKE VA
22015-3750
US

V. Phone/Fax

Practice location:
  • Phone: 703-430-6211
  • Fax: 703-430-1414
Mailing address:
  • Phone: 703-978-1196
  • Fax: 703-978-7762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number0101053112
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number0101057623
License Number StateVA

VIII. Authorized Official

Name: DR. ANTONIO PASTOR
Title or Position: PRESIDENT
Credential: M.D.
Phone: 703-430-6211