Provider Demographics
NPI:1003873159
Name:WILLNER, HENRY S (MD)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:S
Last Name:WILLNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 TELESTAR CT
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-1206
Mailing Address - Country:US
Mailing Address - Phone:703-396-6194
Mailing Address - Fax:703-779-1372
Practice Address - Street 1:2900 TELESTAR CT
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-1206
Practice Address - Country:US
Practice Address - Phone:703-396-6194
Practice Address - Fax:703-779-1372
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010029800207Q00000X
MDD25137207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5615194Medicaid
VAC87775Medicare UPIN
VA80008026Medicare ID - Type Unspecified
VA5615194Medicaid