Provider Demographics
NPI:1902896616
Name:KLADAKIS, MICHELLE T (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:T
Last Name:KLADAKIS
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 1:3015 WILLIAMS DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4623
Mailing Address - Country:US
Mailing Address - Phone:703-698-8800
Mailing Address - Fax:
Practice Address - Street 1:3015 WILLIAMS DR
Practice Address - Street 2:SUITE 200
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4623
Practice Address - Country:US
Practice Address - Phone:703-698-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012446972085R0202X
MDD00621292085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H84640Medicare UPIN
014918D23Medicare UPIN