Provider Demographics
NPI:1013087394
Name:FAIR OAKS INTERNAL MEDICINE
Entity Type:Organization
Organization Name:FAIR OAKS INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MATHEWS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:703-218-2970
Mailing Address - Street 1:10721 MAIN ST
Mailing Address - Street 2:#1500
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6914
Mailing Address - Country:US
Mailing Address - Phone:703-218-2970
Mailing Address - Fax:703-218-2965
Practice Address - Street 1:10721 MAIN ST
Practice Address - Street 2:#1500
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6914
Practice Address - Country:US
Practice Address - Phone:703-218-2970
Practice Address - Fax:703-218-2965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA747997Medicare ID - Type Unspecified
VA747997Medicare UPIN