Basic Information
Provider Information | |||||||||
NPI: | 1184695751 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FANDINO | ||||||||
FirstName: | ERNESTO | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 14 PIDGEON HILL DRIVE | ||||||||
Address2: | STE. 130 | ||||||||
City: | STERLING | ||||||||
State: | VA | ||||||||
PostalCode: | 20165 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7034441144 | ||||||||
FaxNumber: | 7034446679 | ||||||||
Practice Location | |||||||||
Address1: | 14 PIDGEON HILL DRIVE | ||||||||
Address2: | STE. 130 | ||||||||
City: | STERLING | ||||||||
State: | VA | ||||||||
PostalCode: | 20165 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7034441144 | ||||||||
FaxNumber: | 7034446679 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/31/2006 | ||||||||
LastUpdateDate: | 01/26/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 0101040505 | VA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 006730353 | 05 | VA |   | MEDICAID |