Provider Demographics
NPI:1720285893
Name:TERUAKI KODAMA, M.D., L.L.C.
Entity Type:Organization
Organization Name:TERUAKI KODAMA, M.D., L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERUAKI
Authorized Official - Middle Name:
Authorized Official - Last Name:KODAMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-573-6985
Mailing Address - Street 1:8316 ARLINGTON BLVD
Mailing Address - Street 2:SUITE 410
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-5207
Mailing Address - Country:US
Mailing Address - Phone:703-573-6985
Mailing Address - Fax:703-573-7154
Practice Address - Street 1:8316 ARLINGTON BLVD
Practice Address - Street 2:SUITE 410
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-5207
Practice Address - Country:US
Practice Address - Phone:703-573-6985
Practice Address - Fax:703-573-7154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-30
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101048550208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCG00907Medicare PIN