Healthcare Provider Details

I. General information

NPI: 1013144419
Provider Name (Legal Business Name): ERIC M THOMSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2009
Last Update Date: 11/27/2023
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 PARK STREET SE SUITE 300
VIENNA VA
22180
US

IV. Provider business mailing address

12011 LEE JACKSON MEMORIAL HIGHWAY SUITE 504
FAIRFAX VA
22033-3315
US

V. Phone/Fax

Practice location:
  • Phone: 703-255-9100
  • Fax: 703-255-3457
Mailing address:
  • Phone: 703-391-2031
  • Fax: 703-273-3943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0116021437
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number0101247923
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: