MEDICARE: DR. BLAKE R ZELICKSON M.D., PH.D.

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	0101269123	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1902292394
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BLAKE R ZELICKSON M.D., PH.D.

Provider Business Mailing Address
First Line	:	22365 BRODERICK DR STE 115
Second Line	:
City	:	STERLING
State	:	VA
Zip	:	20166-9362
Country	:	US
Telephone Number	:	703-996-4000
Fax Number	:	571-707-8123

Provider Business Practice Location Address
First Line	:	22365 BRODERICK DRIVE, SUITE 115
Second Line	:
City	:	STERLING
State	:	VA
Zip	:	20166-9362
Country	:	US
Telephone Number	:	170-399-6400
Fax Number	:	571-707-8123

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

Provider Enumeration Date	:	04/13/2015
Last Update Date	:	01/05/2026

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Directions to “ DR. BLAKE R ZELICKSON M.D., PH.D.” Practice Location

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