Provider Demographics
NPI:1104819739
Name:MORELAND, ROBERTA MAUREEN (MD)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:MAUREEN
Last Name:MORELAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 17334
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-1334
Mailing Address - Country:US
Mailing Address - Phone:703-723-7171
Mailing Address - Fax:703-723-7176
Practice Address - Street 1:19415 DEERFIELD AVE
Practice Address - Street 2:SUITE 314
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-8452
Practice Address - Country:US
Practice Address - Phone:703-723-7171
Practice Address - Fax:703-723-7176
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101049184207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1104819739Medicaid
0700014603OtherRR MEDICARE
F63195Medicare UPIN
0700014603OtherRR MEDICARE