Provider Demographics
NPI:1649381930
Name:GROW, CONNIE R (DO)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:R
Last Name:GROW
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MAPLE AVE E
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-5723
Mailing Address - Country:US
Mailing Address - Phone:703-938-5300
Mailing Address - Fax:703-242-0726
Practice Address - Street 1:100 MAPLE AVE E
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-5723
Practice Address - Country:US
Practice Address - Phone:703-938-5300
Practice Address - Fax:703-242-0726
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102036977207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000E89I11Medicare UPIN
E43828Medicare UPIN