Provider Demographics
NPI:1508901844
Name:GARTSIDE, ROBERTA LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERTA
Middle Name:LEE
Last Name:GARTSIDE
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 1:1800 TOWN CENTER DR
Mailing Address - Street 2:SUITE 412
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-3215
Mailing Address - Country:US
Mailing Address - Phone:703-742-8004
Mailing Address - Fax:703-742-3749
Practice Address - Street 1:1800 TOWN CENTER DR
Practice Address - Street 2:SUITE 412
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3215
Practice Address - Country:US
Practice Address - Phone:703-742-8004
Practice Address - Fax:703-742-3749
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101042741208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6941648Medicaid
VA6941648Medicaid
G00208Medicare ID - Type Unspecified