Basic Information
Provider Information | |||||||||
NPI: | 1003098351 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MO | ||||||||
FirstName: | FRED | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3800 RESERVOIR RD NW | ||||||||
Address2: |   | ||||||||
City: | WASHINGTON | ||||||||
State: | DC | ||||||||
PostalCode: | 200072113 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2024448766 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3800 RESERVOIR RD NW | ||||||||
Address2: |   | ||||||||
City: | WASHINGTON | ||||||||
State: | DC | ||||||||
PostalCode: | 200072113 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2024448766 | ||||||||
FaxNumber: | 2024441655 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/28/2007 | ||||||||
LastUpdateDate: | 07/02/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0117X | 0101251301 | VA | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 207XS0117X | 255689 | NY | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 207XS0117X | MD042613 | DC | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
No ID Information.