Provider Demographics
NPI:1699964593
Name:POLE, SHRIHARSH
Entity type:Individual
Prefix:
First Name:SHRIHARSH
Middle Name:
Last Name:POLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14904 JEFFERSON DAVIS HWY
Mailing Address - Street 2:SUITE 205
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3908
Mailing Address - Country:US
Mailing Address - Phone:703-497-4500
Mailing Address - Fax:509-463-9780
Practice Address - Street 1:14904 JEFFERSON DAVIS HWY
Practice Address - Street 2:SUITE 205
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3908
Practice Address - Country:US
Practice Address - Phone:703-497-4500
Practice Address - Fax:509-463-9780
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101048251207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA226798OtherBLUE CROSS
VA5836166Medicaid
VA2308844OtherAETNA