Individual
MR. MARK EMANUEL VASILIADIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
12040 S LAKES DR, SUITE 195, RESTON, VA 20191-1246
(703) 230-0347
Mailing address
12040 S LAKES DR STE 204, RESTON, VA 20191-1236
(703) 230-0347
(703) 230-0350
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
0101050406
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
593776473
TAX ID
VA
Enumeration date
11/14/2006
Last updated
08/25/2022
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