Provider Demographics
NPI:1205034659
Name:PEDIATRIC PRACTICE,PC
Entity Type:Organization
Organization Name:PEDIATRIC PRACTICE,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SANJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAMBA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-361-3870
Mailing Address - Street 1:5131 PLEASANT FOREST DR
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120-1249
Mailing Address - Country:US
Mailing Address - Phone:703-803-3282
Mailing Address - Fax:
Practice Address - Street 1:8600 ROLLING RD STE 100
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-3868
Practice Address - Country:US
Practice Address - Phone:703-361-3870
Practice Address - Fax:703-361-3871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-06
Last Update Date:2024-04-19
Deactivation Date:2020-02-27
Deactivation Code:
Reactivation Date:2024-04-19
Provider Licenses
StateLicense IDTaxonomies
VA0101222057208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006702015Medicaid