Basic Information
| Provider Information | |||||||||
| NPI: | 1770608929 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAILES | ||||||||
| FirstName: | TONYA | ||||||||
| MiddleName: | TERESE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1660 COLUMBIA ROAD NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200093697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2023283717 | ||||||||
| FaxNumber: | 2025888101 | ||||||||
| Practice Location | |||||||||
| Address1: | 1660 COLUMBIA ROAD NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200093697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2023283717 | ||||||||
| FaxNumber: | 2025488600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 01/30/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | C50611319 | DC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD036199 | DC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 061712500 | 05 | DC | MEDICAID |