Provider Demographics
NPI:1508841529
Name:HARIADI, JOHN WESLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WESLEY
Last Name:HARIADI
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 1:4200 WILSON BLVD
Mailing Address - Street 2:SUITE 950
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22203-1800
Mailing Address - Country:US
Mailing Address - Phone:202-493-1226
Mailing Address - Fax:
Practice Address - Street 1:4200 WILSON BLVD
Practice Address - Street 2:SUITE 950
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22203-1800
Practice Address - Country:US
Practice Address - Phone:202-493-1226
Practice Address - Fax:202-443-1739
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-10569207Q00000X
AL000248312083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine