Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207QA0505X | Family Doctor - Adult Medicine | 0101023382 | VA |
N | 207QA0505X | Family Doctor - Adult Medicine | D0041392 | MD |
N | 2080A0000X | Adolescent Medicine | 0101023382 | VA |
N | 2080A0000X | Adolescent Medicine | D0041392 | MD |
NPI | 1265531388 |
---|---|
Provider Name | Mr. Jackie Pujol |
First Address | Vienna, VA 22180 |
Second Address | Vienna, VA 22180 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/09/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
101 | (02) | |
6747124 | (05) | VA |