Provider Demographics
NPI:1588829147
Name:JESPERSEN, MARSHA RENEE (MD)
Entity Type:Individual
Prefix:
First Name:MARSHA
Middle Name:RENEE
Last Name:JESPERSEN
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 1:6845 ELM ST #708
Mailing Address - Street 2:
Mailing Address - City:MCLEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101
Mailing Address - Country:US
Mailing Address - Phone:703-893-1111
Mailing Address - Fax:703-760-9565
Practice Address - Street 1:6845 ELM ST #708
Practice Address - Street 2:
Practice Address - City:MCLEAN
Practice Address - State:VA
Practice Address - Zip Code:22101
Practice Address - Country:US
Practice Address - Phone:703-893-1111
Practice Address - Fax:703-760-9565
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-23
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101233956208200000X
MDD74935208200000X
DCMD037518208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC133897YT2Medicare PIN