Provider Demographics
NPI:1306830179
Name:HACKENBERG, VIRGINIA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:MARIE
Last Name:HACKENBERG
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 17334
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-1334
Mailing Address - Country:US
Mailing Address - Phone:703-443-6717
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:19465 DEERFIELD AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-1701
Practice Address - Country:US
Practice Address - Phone:703-858-2811
Practice Address - Fax:703-729-3647
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101044998207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA06203680Medicaid
VA160048809OtherRR MEDICARE
VA06203680Medicaid
VA160001733Medicare PIN