Provider Demographics
NPI:1750342333
Name:HARRISON, STEPHEN G (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:G
Last Name:HARRISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:10691 ALLIWELLS CT
Mailing Address - Street 2:
Mailing Address - City:OAKTON
Mailing Address - State:VA
Mailing Address - Zip Code:22124-1771
Mailing Address - Country:US
Mailing Address - Phone:703-435-3636
Mailing Address - Fax:703-435-9145
Practice Address - Street 1:1830 TOWN CENTER DR
Practice Address - Street 2:SUITE # 205
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3292
Practice Address - Country:US
Practice Address - Phone:703-435-3636
Practice Address - Fax:703-435-9145
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101028882208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6709559Medicaid
VA6709559Medicaid