Provider Demographics
NPI:1780866210
Name:FAIRFAX OAKTON FOOT CENTER LTD
Entity Type:Organization
Organization Name:FAIRFAX OAKTON FOOT CENTER LTD
Other - Org Name:T/A FAUQUIER FOOT HEALTH CTR LTD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:BUNT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:540-347-1370
Mailing Address - Street 1:400B HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:VA
Mailing Address - Zip Code:20186-3026
Mailing Address - Country:US
Mailing Address - Phone:540-347-1370
Mailing Address - Fax:540-349-4801
Practice Address - Street 1:400B HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186-3026
Practice Address - Country:US
Practice Address - Phone:540-347-1370
Practice Address - Fax:540-349-4801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01030000604213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009302166Medicaid
0596180002Medicare NSC
VA009302166Medicaid