Provider Demographics
NPI:1659325744
Name:GEOLYY, KENNETH (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:GEOLYY
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 1:4915 AUBURN AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-2636
Mailing Address - Country:US
Mailing Address - Phone:301-907-3939
Mailing Address - Fax:301-656-3943
Practice Address - Street 1:8316 ARLINGTON BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-5207
Practice Address - Country:US
Practice Address - Phone:703-560-1313
Practice Address - Fax:703-876-0824
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101057939207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6034501Medicaid
DC056324Medicare ID - Type Unspecified
VA6034501Medicaid