Provider Demographics
NPI:1043577190
Name:GOYAL, SAMITA SALLY (MD)
Entity Type:Individual
Prefix:
First Name:SAMITA
Middle Name:SALLY
Last Name:GOYAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 MILLER DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22315-3528
Mailing Address - Country:US
Mailing Address - Phone:703-626-6165
Mailing Address - Fax:
Practice Address - Street 1:3960 STILLMAN PKWY
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-4197
Practice Address - Country:US
Practice Address - Phone:804-270-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-13
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI61439208200000X
VA01012661332086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1043577190Medicaid