Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 207R00000X | Internal Medicine | | 0101026604 | VIRGINIA | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | C01468 | MEDICARE ID-TYPE UNSPECIFIED | | GROUP MEDICARE NUMBER |
| 2 | 0000000003812 | OTHER | VIRGINIA | ANTHEM BCBS GROUP NUMBER |
| 3 | 016650 | OTHER | VIRGINIA | ANTHEM BCBS OF VA |
| 4 | 101268 | OTHER | VIRGINIA | CIGNA HEALTHCARE |
| 5 | 110019575 | OTHER | | RAILROAD MEDICARE |
| 6 | B09913 | MEDICARE UPIN | | |
| 7 | 541272601 | OTHER | | EIN |
| 8 | C12158 | MEDICARE ID-TYPE UNSPECIFIED | | GROUP RAILROAD MEDICARE # |
| 9 | 110000690 | MEDICARE ID-TYPE UNSPECIFIED | | |
| 10 | 22008 | OTHER | VIRGINIA | SENTARA OPTIMA OF VIRGINA |
| 11 | 200144 | OTHER | VIRGINIA | SENTARA OPTIMA VENDOR # |
| 12 | 6075304 | MEDICAID | VIRGINIA | |
