Provider Demographics
NPI:1184731796
Name:LOUDOUN MEDICAL GROUP PC
Entity type:Organization
Organization Name:LOUDOUN MEDICAL GROUP PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MUKESH
Authorized Official - Middle Name:D
Authorized Official - Last Name:BHAKTA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:703-753-3338
Mailing Address - Street 1:7430 HERITAGE VILLAGE PLZ
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155-3088
Mailing Address - Country:US
Mailing Address - Phone:703-753-3338
Mailing Address - Fax:703-753-7870
Practice Address - Street 1:7430 HERITAGE VILLAGE PLAZA
Practice Address - Street 2:SUITE 101
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155
Practice Address - Country:US
Practice Address - Phone:703-753-3338
Practice Address - Fax:703-753-7870
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOUDOUN MEDICAL GROUP, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-23
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6006900001Medicare NSC
VAC09943Medicare PIN