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General NPI Number Information
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NPI Number | 1831647239
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Entity Type | Organization
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Legal Business Name | FAIRFAX INTERNAL MEDICINE AND PRIMARY CARE PC
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Dates
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Enumeration Date | 09/14/2016
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Last Update Date | 09/14/2016
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Provider Practice Location Address
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Address Line | 5618 OX RD SUITE D-2
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City | FAIRFAX STATION
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State | VA
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Zip | 22039
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Country | US
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Telephone | 703-291-0405
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Fax | 703-337-0377
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Provider Business Mailing Address
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Address Line | 5618 OX RD SUITE D-2
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City | FAIRFAX STATION
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State | VA
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Zip | 22039
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Country | US
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Telephone | 703-291-0405
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Fax | 703-337-0377
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Authorized Official
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Title or Position | PHYSICIAN
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Name | KARUNA GALLA
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Credential | M.D
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Telephone | 703-291-0405
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 0101250312
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License Number State | VA
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