Healthcare Provider Details

I. General information

NPI: 1417053794
Provider Name (Legal Business Name): ALEXANDRIA LAKE RIDGE PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1990 OLD BRIDGE RD SUITE 101
WOODBRIDGE VA
22192-2383
US

IV. Provider business mailing address

4660 KENMORE AVE SUITE 500
ALEXANDRIA VA
22304-1313
US

V. Phone/Fax

Practice location:
  • Phone: 703-212-6600
  • Fax: 703-931-0961
Mailing address:
  • Phone: 703-212-6600
  • Fax: 703-931-0961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. DEBORAH WEESE
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 703-212-6600