Provider Demographics
NPI:1447205513
Name:GISOLFI, ROGER VICTOR (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:VICTOR
Last Name:GISOLFI
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:P O BOX 829
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22306
Mailing Address - Country:US
Mailing Address - Phone:703-664-7189
Mailing Address - Fax:410-793-0809
Practice Address - Street 1:2501 PARKERS LN
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306-3209
Practice Address - Country:US
Practice Address - Phone:703-664-7189
Practice Address - Fax:410-793-0809
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA267220208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6834159Medicaid
VAB94864Medicare UPIN
VA426756M65Medicare ID - Type UnspecifiedMEDICARE