Provider Demographics
NPI:1740215391
Name:PROSKY, MARTIN G (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:G
Last Name:PROSKY
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 1:3301 WOODBURN RD STE 107
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-1297
Mailing Address - Country:US
Mailing Address - Phone:703-876-0437
Mailing Address - Fax:703-876-0722
Practice Address - Street 1:3301 WOODBURN RD
Practice Address - Street 2:SUITE #107
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-1229
Practice Address - Country:US
Practice Address - Phone:703-876-0437
Practice Address - Fax:703-876-0722
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0101045301174400000X
VA0101045301207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0613370Medicare ID - Type Unspecified
VAE70218Medicare UPIN
VA612700Medicare PIN