Healthcare Provider Details

I. General information

NPI: 1467416305
Provider Name (Legal Business Name): DOUGLAS EDWIN HERITAGE M.D.09
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2026A OPITZ BLVD
WOODBRIDGE VA
22191-3306
US

IV. Provider business mailing address

2026A OPITZ BLVD
WOODBRIDGE VA
22191-3306
US

V. Phone/Fax

Practice location:
  • Phone: 703-491-7155
  • Fax: 703-690-3958
Mailing address:
  • Phone: 703-491-7155
  • Fax: 703-690-3958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0101027756
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: