Provider Demographics
NPI:1881688844
Name:SUGHRUE, MAURA JEAN (MD)
Entity Type:Individual
Prefix:
First Name:MAURA
Middle Name:JEAN
Last Name:SUGHRUE
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:PO BOX 791128
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-1128
Mailing Address - Country:US
Mailing Address - Phone:703-391-2020
Mailing Address - Fax:703-391-1211
Practice Address - Street 1:3650 JOSEPH SIEWICK DR
Practice Address - Street 2:STE 400
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1710
Practice Address - Country:US
Practice Address - Phone:703-391-2020
Practice Address - Fax:703-391-1211
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101035222207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA080182899OtherRR MEDICARE
VA05622409Medicaid
VA005622409Medicaid