Provider Demographics
NPI:1245362581
Name:SOVEROW, GARY JAN (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:JAN
Last Name:SOVEROW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6888 ELM ST
Mailing Address - Street 2:SUITE 3C
Mailing Address - City:MCLEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3829
Mailing Address - Country:US
Mailing Address - Phone:703-821-1324
Mailing Address - Fax:703-821-1324
Practice Address - Street 1:6888 ELM ST
Practice Address - Street 2:SUITE 3C
Practice Address - City:MCLEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3829
Practice Address - Country:US
Practice Address - Phone:703-821-1324
Practice Address - Fax:703-821-1324
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010290672084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
B93664Medicare UPIN
145572Medicare ID - Type Unspecified