Provider Demographics
NPI:1609984897
Name:SELVAGGI, NINA (MD)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:SELVAGGI
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 1:3022 WILLIAMS DRIVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031
Mailing Address - Country:US
Mailing Address - Phone:703-573-9800
Mailing Address - Fax:703-573-2959
Practice Address - Street 1:3022 WILLIAMS DRIVE
Practice Address - Street 2:SUITE 300
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031
Practice Address - Country:US
Practice Address - Phone:703-573-9800
Practice Address - Fax:703-573-2959
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101043382207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6037909Medicaid
110153967OtherRR MEDICARE
VA6037909Medicaid
E23603Medicare UPIN