Provider Demographics
NPI:1114929247
Name:TANENBAUM, MARK P (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:P
Last Name:TANENBAUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2901 TELESTAR CT.
Mailing Address - Street 2:#300
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-1263
Mailing Address - Country:US
Mailing Address - Phone:703-591-1688
Mailing Address - Fax:703-591-1445
Practice Address - Street 1:3580 JOSEPH SIEWICK DR STE 305
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1764
Practice Address - Country:US
Practice Address - Phone:703-648-3266
Practice Address - Fax:703-648-3264
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101043105207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC031738500Medicaid
DC060035106OtherRAILROAD MEDICARE DC #
VA060062627OtherRAILROAD MEDICARE VA #
VA1114929247Medicaid
MD121300800Medicaid
DC031738500Medicaid
VA060000661Medicare PIN
VA1114929247Medicaid
VA6026222Medicaid
VA005871794Medicaid