Healthcare Provider Details

I. General information

NPI: 1033519855
Provider Name (Legal Business Name): CASA PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2014
Last Update Date: 08/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14130 NOBLEWOOD PLZ SUITE 306
WOODBRIDGE VA
22193-1464
US

IV. Provider business mailing address

14130 NOBLEWOOD PLZ SUITE 306
WOODBRIDGE VA
22193-1464
US

V. Phone/Fax

Practice location:
  • Phone: 703-485-0470
  • Fax: 703-986-0825
Mailing address:
  • Phone: 703-485-0470
  • Fax: 703-986-0825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARTHA LISSETT CASAMALHUAPA CALDERON
Title or Position: CEO / MEDICAL DIRECTOR
Credential: M.D.
Phone: 703-485-0470