Provider Demographics
NPI:1558452763
Name:FAMILY PRACTICE OF WINCHESTER PLLC
Entity Type:Organization
Organization Name:FAMILY PRACTICE OF WINCHESTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MILTON
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:HAVRON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:540-723-8992
Mailing Address - Street 1:442 FAIRMONT AVE
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-3929
Mailing Address - Country:US
Mailing Address - Phone:540-723-8992
Mailing Address - Fax:
Practice Address - Street 1:442 FAIRMONT AVE
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601
Practice Address - Country:US
Practice Address - Phone:540-723-8992
Practice Address - Fax:540-722-1120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101055962174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005638691Medicaid
VA005638691Medicaid