Provider Demographics
NPI:1184719692
Name:SARGENT, DONALD LEE (MD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:LEE
Last Name:SARGENT
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 1:2241-M TACKETTS MILL DRIVE
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192
Mailing Address - Country:US
Mailing Address - Phone:703-494-7530
Mailing Address - Fax:703-497-1682
Practice Address - Street 1:2241-M TACKETTS MILL DRIVE
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192
Practice Address - Country:US
Practice Address - Phone:703-494-7530
Practice Address - Fax:703-497-1682
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-039909207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VIB08427Medicare UPIN
VA0800001809Medicare ID - Type UnspecifiedMEDICARE