Healthcare Provider Details

I. General information

NPI: 1891742789
Provider Name (Legal Business Name): GEORGIS G KEFALE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 OPITZ BLVD
WOODBRIDGE VA
22191-3311
US

IV. Provider business mailing address

2730-B PROSPERITY AVENUE
FAIRFAX VA
22031-2238
US

V. Phone/Fax

Practice location:
  • Phone: 703-289-1400
  • Fax: 703-289-1414
Mailing address:
  • Phone: 703-289-1400
  • Fax: 703-289-1414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number0101041109
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: