Provider Demographics
NPI:1952812364
Name:VIRGINIA ID DOCTORS LLC
Entity Type:Organization
Organization Name:VIRGINIA ID DOCTORS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAVANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:NUTANKALVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:571-477-9909
Mailing Address - Street 1:4437 BROOKFIELD CORPORATE DR STE 101
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-2122
Mailing Address - Country:US
Mailing Address - Phone:703-738-9989
Mailing Address - Fax:703-738-9991
Practice Address - Street 1:1860 TOWN CENTER DR STE 310
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5899
Practice Address - Country:US
Practice Address - Phone:703-738-9989
Practice Address - Fax:703-738-9991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-12
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101240702207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty