Provider Demographics
NPI:1902292394
Name:ZELICKSON, BLAKE REID (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:REID
Last Name:ZELICKSON
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:224D CORNWALL ST NW STE 403
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6001
Mailing Address - Fax:901-448-1299
Practice Address - Street 1:22365 BRODERICK DRIVE, SUITE 115
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20166-9362
Practice Address - Country:US
Practice Address - Phone:170-399-6400
Practice Address - Fax:571-707-8123
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-13
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY286353207N00000X
VA0101269123207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1902292394Medicaid
VA30017647860001Medicaid