Provider Demographics
NPI:1477870541
Name:BOURGET, MARIYA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIYA
Middle Name:
Last Name:BOURGET
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 1:14330 GIDEON DR STE B
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-4640
Mailing Address - Country:US
Mailing Address - Phone:571-408-6800
Mailing Address - Fax:703-910-7021
Practice Address - Street 1:14330 GIDEON DR STE B
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-4640
Practice Address - Country:US
Practice Address - Phone:571-408-6800
Practice Address - Fax:703-910-7021
Is Sole Proprietor?:No
Enumeration Date:2010-04-28
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101247265207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA191304YW1Medicare UPIN