Provider Demographics
NPI:1184848004
Name:MENNEN, BARNETT G (MD)
Entity Type:Individual
Prefix:DR
First Name:BARNETT
Middle Name:G
Last Name:MENNEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:BARRY
Other - Middle Name:G
Other - Last Name:MENNEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1880 HOWARD AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2667
Mailing Address - Country:US
Mailing Address - Phone:703-790-0103
Mailing Address - Fax:703-790-0379
Practice Address - Street 1:1880 HOWARD AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-2667
Practice Address - Country:US
Practice Address - Phone:703-790-0103
Practice Address - Fax:790-703-0379
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0072173207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD0072173OtherSTATE LICENSE
VA0101248289OtherSTATE LICENSE