Provider Demographics
NPI:1699760371
Name:PHILLIPS, JOHN KEITH (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:KEITH
Last Name:PHILLIPS
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:PO BOX 791128
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-1128
Mailing Address - Country:US
Mailing Address - Phone:703-391-2030
Mailing Address - Fax:703-273-3943
Practice Address - Street 1:4080 LAFAYETTE CENTER DR
Practice Address - Street 2:SUITE 170
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-1247
Practice Address - Country:US
Practice Address - Phone:703-766-5040
Practice Address - Fax:703-766-5047
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2012-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101231142207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA05647398Medicaid
VAP00015942OtherRR MEDICARE
H54864Medicare UPIN
VA008999F32Medicare ID - Type Unspecified