Provider Demographics
NPI:1316182116
Name:ALEXANDRIA LAKE RIDGE PEDIATRICS
Entity Type:Organization
Organization Name:ALEXANDRIA LAKE RIDGE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:M
Authorized Official - Last Name:FARBER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-212-6600
Mailing Address - Street 1:1707 OSAGE ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-2607
Mailing Address - Country:US
Mailing Address - Phone:703-212-6600
Mailing Address - Fax:703-931-0961
Practice Address - Street 1:9010 LORTON STATION BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:LORTON
Practice Address - State:VA
Practice Address - Zip Code:22079
Practice Address - Country:US
Practice Address - Phone:703-212-6600
Practice Address - Fax:703-931-0961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-08
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101038289208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty