Healthcare Provider Details

I. General information

NPI: 1104528314
Provider Name (Legal Business Name): MARIA DANIELLE SUGASTTI BALCAZAR DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2023
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 OPITZ BLVD STE 355
WOODBRIDGE VA
22191-3340
US

IV. Provider business mailing address

2200 OPITZ BLVD STE 355
WOODBRIDGE VA
22191-3340
US

V. Phone/Fax

Practice location:
  • Phone: 703-580-6400
  • Fax:
Mailing address:
  • Phone: 703-580-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0102210349
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: