Provider Demographics
NPI:1437101508
Name:THEISZ, GORDON W (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:W
Last Name:THEISZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 E BROAD ST STE A
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-4530
Mailing Address - Country:US
Mailing Address - Phone:703-533-7555
Mailing Address - Fax:703-533-7797
Practice Address - Street 1:124 E BROAD ST STE A
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-4530
Practice Address - Country:US
Practice Address - Phone:703-533-7555
Practice Address - Fax:703-533-7797
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101102617207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010189781Medicaid
VAP00377886OtherRAILROAD MEDICARE
VAP00377886OtherRAILROAD MEDICARE
VAH47850Medicare UPIN
VAG02125F01Medicare ID - Type UnspecifiedPRIVATE PRACTICE #