Provider Demographics
NPI:1477561231
Name:FENDER, GARY R (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:R
Last Name:FENDER
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 1:3022 WILLIAMS DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031
Mailing Address - Country:US
Mailing Address - Phone:703-573-9800
Mailing Address - Fax:703-573-2959
Practice Address - Street 1:3022 WILLIAMS DR
Practice Address - Street 2:SUITE 300
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031
Practice Address - Country:US
Practice Address - Phone:703-573-9800
Practice Address - Fax:703-573-2959
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101034449207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
11007547OtherRR MEDICARE
VA6072291Medicaid
B94887Medicare UPIN
429605G45Medicare PIN