Basic Information
| Provider Information | |||||||||
| NPI: | 1184294357 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOBILE MEDICAL HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MOBILE MEDICAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 44330 MERCURE CIR STE 240E | ||||||||
| Address2: | |||||||||
| City: | DULLES | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201662024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037270523 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 44330 MERCURE CIR STE 240E | ||||||||
| Address2: | |||||||||
| City: | DULLES | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201662024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037270523 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2021 | ||||||||
| LastUpdateDate: | 07/08/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EUSTAQUIO | ||||||||
| AuthorizedOfficialFirstName: | DOUG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7039350330 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 12196770 | 01 | CAQH | OTHER | 1982640405 | 01 | VA | NPPES | OTHER |