Provider Demographics
NPI:1730116658
Name:GARNER, FREDRIC BRUCE (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDRIC
Middle Name:BRUCE
Last Name:GARNER
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 1:8988 FERN PARK DR
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-1635
Mailing Address - Country:US
Mailing Address - Phone:703-978-6061
Mailing Address - Fax:703-978-0291
Practice Address - Street 1:8988 FERN PARK DR
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-1635
Practice Address - Country:US
Practice Address - Phone:703-978-6061
Practice Address - Fax:703-978-0291
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2013-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101017927208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006727352Medicaid
VA006727352Medicaid