Provider Demographics
NPI:1770569451
Name:WOLDEGEBRIEL, THEODROS (MSPT, DPT)
Entity type:Individual
Prefix:
First Name:THEODROS
Middle Name:
Last Name:WOLDEGEBRIEL
Suffix:
Gender:M
Credentials:MSPT, DPT
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 1769
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20118-1769
Mailing Address - Country:US
Mailing Address - Phone:540-687-8181
Mailing Address - Fax:540-687-8256
Practice Address - Street 1:8101 HINSON FARM RD
Practice Address - Street 2:SUITE 312
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306-3403
Practice Address - Country:US
Practice Address - Phone:703-360-6175
Practice Address - Fax:703-360-6477
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305203064225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC016762T86Medicare PIN
DCQ16462Medicare UPIN