=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265435523
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EVELINE B MARQUARDT M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 TOWN CENTER DR STE 319
-----------------------------------------------------
City | RESTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20190-3239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-668-0520
-----------------------------------------------------
Fax | 703-668-0525
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1800 TOWN CENTER DR STE 319
-----------------------------------------------------
City | RESTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20190-3239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-668-0520
-----------------------------------------------------
Fax | 703-668-0525
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 0101043271
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------