Provider Demographics
NPI:1225042195
Name:MAYBACH, ANITA M (MD)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:M
Last Name:MAYBACH
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:PO BOX 223323
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20153-3323
Mailing Address - Country:US
Mailing Address - Phone:540-349-0595
Mailing Address - Fax:540-349-0587
Practice Address - Street 1:500 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186-3027
Practice Address - Country:US
Practice Address - Phone:540-349-0595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101230734208D00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010206405Medicaid
VA010167108Medicaid
VAP00332818Medicare PIN
VA010167108Medicaid
VA007546V59Medicare PIN