Provider Demographics
NPI:1366729675
Name:ERIC S. HAVENS P L L C
Entity type:Organization
Organization Name:ERIC S. HAVENS P L L C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:S
Authorized Official - Last Name:HAVENS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:703-834-7584
Mailing Address - Street 1:1850 TOWN CENTER PKWY STE 207
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-3219
Mailing Address - Country:US
Mailing Address - Phone:703-478-9390
Mailing Address - Fax:
Practice Address - Street 1:1850 TOWN CENTER PKWY STE 207
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3219
Practice Address - Country:US
Practice Address - Phone:703-478-9390
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
490852Medicare PIN