Provider Demographics
NPI:1336334275
Name:MEDICAL CLINIC OF WOODBRIDGE INC
Entity Type:Organization
Organization Name:MEDICAL CLINIC OF WOODBRIDGE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:OBIORAH
Authorized Official - Last Name:NWUFOH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-497-1964
Mailing Address - Street 1:12716 DIRECTORS LOOP
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192
Mailing Address - Country:US
Mailing Address - Phone:703-497-1964
Mailing Address - Fax:703-497-9885
Practice Address - Street 1:12716 DIRECTORS LOOP
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192
Practice Address - Country:US
Practice Address - Phone:703-497-1964
Practice Address - Fax:703-497-9885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2021-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0101057783207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005821037Medicaid