Provider Demographics
NPI:1710044706
Name:JAN PAUL FRUITERMAN MD & ASSOCIATES, PC
Entity Type:Organization
Organization Name:JAN PAUL FRUITERMAN MD & ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:FRUITERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-425-5100
Mailing Address - Street 1:13880 BRADDOCK ROAD, SUITE 307
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-2438
Mailing Address - Country:US
Mailing Address - Phone:703-425-5100
Mailing Address - Fax:703-425-8803
Practice Address - Street 1:13880 BRADDOCK RD STE 307
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-2462
Practice Address - Country:US
Practice Address - Phone:703-425-5100
Practice Address - Fax:703-425-8803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD0101029267207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA700743Medicare ID - Type UnspecifiedGROUP MEDICARE