Provider Demographics
NPI:1518050558
Name:FISK, DANIEL RICHARD (MD)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:RICHARD
Last Name:FISK
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 1:4001 FAIR RIDGE DR STE 304
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2917
Mailing Address - Country:US
Mailing Address - Phone:703-861-5564
Mailing Address - Fax:703-549-3642
Practice Address - Street 1:4001 FAIR RIDGE DR STE 304
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2917
Practice Address - Country:US
Practice Address - Phone:703-861-5564
Practice Address - Fax:703-549-3642
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101228931207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010141273Medicaid
G019545T01Medicare ID - Type Unspecified