Provider Demographics
NPI:1568560134
Name:GIANGERUSO, ENRICO A (MD)
Entity Type:Individual
Prefix:
First Name:ENRICO
Middle Name:A
Last Name:GIANGERUSO
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 1:224D CORNWALL ST NW STE 403
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:571-291-9786
Practice Address - Street 1:4660 KENMORE AVENUE, SUITE 305
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1306
Practice Address - Country:US
Practice Address - Phone:703-751-5763
Practice Address - Fax:703-370-8704
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101258831207ZB0001X, 207ZC0006X, 207ZP0102X
MDD0044362207ZB0001X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion Medicine
No207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1568560134Medicaid
VA30016323590001Medicaid
MD61489901OtherBLUE SHIELD
DCW2270004OtherGHI
MD135291100Medicaid