Provider Demographics
NPI:1942311675
Name:NOVA INTERNAL MEDICINE, INC
Entity Type:Organization
Organization Name:NOVA INTERNAL MEDICINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAKSHMI
Authorized Official - Middle Name:
Authorized Official - Last Name:BHAGAVATHULA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-560-1733
Mailing Address - Street 1:9582 BRONTE DR
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-1758
Mailing Address - Country:US
Mailing Address - Phone:703-560-1733
Mailing Address - Fax:703-426-2428
Practice Address - Street 1:611 S CARLIN SPRINGS RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22204-1064
Practice Address - Country:US
Practice Address - Phone:703-560-1733
Practice Address - Fax:703-426-2428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101233031207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG02196Medicare ID - Type Unspecified