Provider Demographics
NPI:1952583650
Name:DREW, PHYLLIS JEAN (MD)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:JEAN
Last Name:DREW
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 1:9683-A MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-3755
Mailing Address - Country:US
Mailing Address - Phone:703-426-4900
Mailing Address - Fax:704-426-4955
Practice Address - Street 1:9683-A MAIN STREET
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-3755
Practice Address - Country:US
Practice Address - Phone:703-426-4900
Practice Address - Fax:704-426-4955
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-04
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101046952207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAE89139Medicare UPIN
VA187798Medicare PIN