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General NPI Number Information
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NPI Number | 1902292394
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Entity Type | Individual
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Provider Name | BLAKE R ZELICKSON M.D., PH.D.
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Gender | Male
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Dates
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Enumeration Date | 04/13/2015
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Last Update Date | 01/05/2026
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Provider Practice Location Address
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Address Line | 22365 BRODERICK DRIVE, SUITE 115
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City | STERLING
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State | VA
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Zip | 20166-9362
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Country | US
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Telephone | 170-399-6400
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Fax | 571-707-8123
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Provider Business Mailing Address
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Address Line | 22365 BRODERICK DR STE 115
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City | STERLING
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State | VA
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Zip | 20166-9362
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Country | US
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Telephone | 703-996-4000
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Fax | 571-707-8123
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 0101269123
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License Number State | VA
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