Provider Demographics
NPI:1669496790
Name:DIAGENETICS OF FREDERICKSBURG
Entity Type:Organization
Organization Name:DIAGENETICS OF FREDERICKSBURG
Other - Org Name:DIAGENETICS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:STETKA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:540-854-0125
Mailing Address - Street 1:PO BOX 2510
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:VA
Mailing Address - Zip Code:22508-8510
Mailing Address - Country:US
Mailing Address - Phone:540-854-0120
Mailing Address - Fax:540-854-0126
Practice Address - Street 1:32315 CONSTITUTION HWY
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:VA
Practice Address - Zip Code:22508-2707
Practice Address - Country:US
Practice Address - Phone:540-854-0120
Practice Address - Fax:540-854-0126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC1700OtherCARE FIRST BC/BS
VA261261OtherANTHEM BC/BS