Provider Demographics
NPI:1689632028
Name:FUGATE, CANDACE (MD)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:FUGATE
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 1:3914 CENTREVILLE RD
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-3289
Mailing Address - Country:US
Mailing Address - Phone:703-481-8600
Mailing Address - Fax:855-308-2338
Practice Address - Street 1:3914 CENTREVILLE RD STE 101
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-3289
Practice Address - Country:US
Practice Address - Phone:703-481-8600
Practice Address - Fax:703-481-8618
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101057927208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6714463Medicaid
VA6733999Medicaid
VA6714463Medicaid