Provider Demographics
NPI:1184294357
Name:MOBILE MEDICAL HEALTH
Entity type:Organization
Organization Name:MOBILE MEDICAL HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:EUSTAQUIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-935-0330
Mailing Address - Street 1:44330 MERCURE CIR STE 240E
Mailing Address - Street 2:
Mailing Address - City:DULLES
Mailing Address - State:VA
Mailing Address - Zip Code:20166-2024
Mailing Address - Country:US
Mailing Address - Phone:703-727-0523
Mailing Address - Fax:
Practice Address - Street 1:44330 MERCURE CIR STE 240E
Practice Address - Street 2:
Practice Address - City:DULLES
Practice Address - State:VA
Practice Address - Zip Code:20166-2024
Practice Address - Country:US
Practice Address - Phone:703-727-0523
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-29
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
12196770OtherCAQH
VA1982640405OtherNPPES