Provider Demographics
NPI:1639241771
Name:VASILIADIS, MARK EMANUEL (MD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:EMANUEL
Last Name:VASILIADIS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:12040 S LAKES DR STE 204
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-1236
Mailing Address - Country:US
Mailing Address - Phone:703-230-0347
Mailing Address - Fax:703-230-0350
Practice Address - Street 1:12040 S LAKES DR
Practice Address - Street 2:SUITE 195
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-1246
Practice Address - Country:US
Practice Address - Phone:703-230-0347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101050406207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA593776473OtherTAX ID
VAF81567Medicare UPIN