Basic Information
Provider Information | |||||||||
NPI: | 1265471676 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EDMOND-DAVIS | ||||||||
FirstName: | VICTORIA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | EDMOND DAVIS | ||||||||
OtherFirstName: | VICTORIA | ||||||||
OtherMiddleName: | J | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 2722 MERRILEE DR | ||||||||
Address2: | STE 230 | ||||||||
City: | FAIRFAX | ||||||||
State: | VA | ||||||||
PostalCode: | 220314400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7036984483 | ||||||||
FaxNumber: | 7035730880 | ||||||||
Practice Location | |||||||||
Address1: | 2722 MERRILEE DR | ||||||||
Address2: | STE 230 | ||||||||
City: | FAIRFAX | ||||||||
State: | VA | ||||||||
PostalCode: | 220314400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7036984483 | ||||||||
FaxNumber: | 7035730880 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/05/2006 | ||||||||
LastUpdateDate: | 01/27/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/27/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | D0087992 | MD | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 0101240073 | VA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 0090 | 01 | VA | CAREFIRST BCBS | OTHER | 260000 | 01 | VA | KAISER | OTHER | 200381160 | 05 | IN |   | MEDICAID | 010304083 | 05 | VA |   | MEDICAID | 1371666 | 01 | VA | AETNA HMO | OTHER | 010304105 | 05 | VA |   | MEDICAID | 7278394 | 01 | VA | AETNA | OTHER |