Provider Demographics
NPI:1386821536
Name:HEISKELL, MELODY ROSE (MD)
Entity Type:Individual
Prefix:DR
First Name:MELODY
Middle Name:ROSE
Last Name:HEISKELL
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 1:2005 BEACON PL
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-4843
Mailing Address - Country:US
Mailing Address - Phone:404-290-1244
Mailing Address - Fax:
Practice Address - Street 1:8316 ARLINGTON BLVD STE 300
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-5216
Practice Address - Country:US
Practice Address - Phone:703-573-2432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-29
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002165208000000X
VA0101245374208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101245374OtherVIRGINIA LICENSE