Provider Demographics
NPI:1811133218
Name:DE NOVA CLINIC PC.
Entity type:Organization
Organization Name:DE NOVA CLINIC PC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MAHER
Authorized Official - Middle Name:A
Authorized Official - Last Name:HUTTAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-858-9494
Mailing Address - Street 1:PO BOX 4495
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22044-0495
Mailing Address - Country:US
Mailing Address - Phone:703-858-9494
Mailing Address - Fax:
Practice Address - Street 1:6400 ARLINGTON BLVD
Practice Address - Street 2:SUITE 940
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-2325
Practice Address - Country:US
Practice Address - Phone:703-858-9494
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-06
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101241929208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty