Individual
DR. BLAKE R ZELICKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D., PH.D.
Contact information
Practice address
22365 BRODERICK DRIVE, SUITE 115, STERLING, VA 20166-9362
(170) 399-6400
(571) 707-8123
Mailing address
22365 BRODERICK DR STE 115, STERLING, VA 20166-9362
(703) 996-4000
(571) 707-8123
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
0101269123
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1902292394
—
VA
05
—
30017647860001
—
VA
Enumeration date
04/13/2015
Last updated
01/05/2026
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