Provider Demographics
NPI:1427061381
Name:BOMMASANI, REENA RAO (MD)
Entity type:Individual
Prefix:DR
First Name:REENA
Middle Name:RAO
Last Name:BOMMASANI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13168 CENTERPOINTE WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-5287
Mailing Address - Country:US
Mailing Address - Phone:703-730-2000
Mailing Address - Fax:703-730-6767
Practice Address - Street 1:13168 CENTERPOINTE WAY STE 101
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-5287
Practice Address - Country:US
Practice Address - Phone:703-730-2000
Practice Address - Fax:703-730-6767
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101236174207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010314241Medicaid
VA1427061381Medicaid
VA010314216Medicaid
VA00X851M01Medicare PIN