Provider Demographics
NPI:1174614655
Name:NATHAN, MICHAEL JAY (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAY
Last Name:NATHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2616 SHERWOOD HALL LN
Mailing Address - Street 2:SUITE 411
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22306-3100
Mailing Address - Country:US
Mailing Address - Phone:703-780-5073
Mailing Address - Fax:
Practice Address - Street 1:2616 SHERWOOD HALL LN
Practice Address - Street 2:SUITE 411
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306-3100
Practice Address - Country:US
Practice Address - Phone:703-780-5073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101042969207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC59427Medicare UPIN
VA170190Medicare ID - Type Unspecified