MEDICARE: DR. LUCAS KIDD GWYNN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	0101223967	VA
2	207Q00000X	Family Medicine Physician	0101223967	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	146092	OTHER	VA	ANTHEM BCBS
2	279883	OTHER	VA	AMERIGROUP

General Provider Information

NPI Number	:	1588681274
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LUCAS KIDD GWYNN MD

Provider Business Mailing Address
First Line	:	6408 SEVEN CORNERS PL
Second Line	:	SUITE J
City	:	FALLS CHURCH
State	:	VA
Zip	:	22044-2011
Country	:	US
Telephone Number	:	703-531-1030
Fax Number	:	703-531-1031

Provider Business Practice Location Address
First Line	:	6408 SEVEN CORNERS PL
Second Line	:	SUITE J
City	:	FALLS CHURCH
State	:	VA
Zip	:	22044-2034
Country	:	US
Telephone Number	:	703-531-1030
Fax Number	:	703-531-1031

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	09/11/2025

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