Provider Demographics
NPI:1740288315
Name:GRUNDLEHNER, MARIETTA F (MD)
Entity type:Individual
Prefix:DR
First Name:MARIETTA
Middle Name:F
Last Name:GRUNDLEHNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 JOSEPH SIEWICK DR
Mailing Address - Street 2:#305
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-1744
Mailing Address - Country:US
Mailing Address - Phone:703-476-1740
Mailing Address - Fax:703-476-6432
Practice Address - Street 1:3700 JOSEPH SIEWICK DR
Practice Address - Street 2:#305
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1744
Practice Address - Country:US
Practice Address - Phone:703-476-1740
Practice Address - Fax:703-476-6432
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101032626174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004075N55Medicare ID - Type UnspecifiedGROUP C06555
VAD84595Medicare UPIN
VA013490N18Medicare ID - Type UnspecifiedGROUP 172118