Provider Demographics
NPI:1720259054
Name:FAIRFAX ENT & FACIAL PLASTIC SURGERY, PC
Entity Type:Organization
Organization Name:FAIRFAX ENT & FACIAL PLASTIC SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURENCE
Authorized Official - Middle Name:R
Authorized Official - Last Name:O'HALLORAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-573-3687
Mailing Address - Street 1:8120 GATEHOUSE RD
Mailing Address - Street 2:#3
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-1204
Mailing Address - Country:US
Mailing Address - Phone:703-573-3687
Mailing Address - Fax:703-204-0114
Practice Address - Street 1:8120 GATEHOUSE RD
Practice Address - Street 2:#3
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-1204
Practice Address - Country:US
Practice Address - Phone:703-573-3687
Practice Address - Fax:703-204-0114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-14
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101051134207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & NeckGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAE58500Medicare PIN
VAH86226Medicare UPIN