Provider Demographics
NPI:1295772275
Name:KONGSTVEDT, PETER REID (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:REID
Last Name:KONGSTVEDT
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 1:1464 BUENA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3510
Mailing Address - Country:US
Mailing Address - Phone:703-442-8908
Mailing Address - Fax:
Practice Address - Street 1:11951 FREEDOM DR
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5640
Practice Address - Country:US
Practice Address - Phone:703-947-2489
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101046055207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine