Individual ProviderWibisono HartojoInternal MedicineAllopathic & Osteopathic PhysiciansPractice Address3300 Gallows Rd, Falls Church, VA 22042-3307(703) 776-4401PECOS EnrollmentBased on the most recent information from CMS, provider Wibisono Hartojo is legally eligible to order and refer claims for Part B, HHA, DME and PMD services.Part BMedicare Part BEnrolledHHAHome Health AgencyEnrolledDMEDurable Medical EquipmentEnrolledPMDPower Mobility DeviceEnrolledCMS last updated its PECOS records today at 10:37 AM.Profile DetailsProvider ID1487883740Provider TypeIndividualFull NameHartojo, WibisonoTitleMr.CredentialMDGenderMaleSole ProprietorNoEnumeration Date7/8/2009Last Updated5/10/2021Contact InformationPractice LocationPractice Address3300 Gallows Rd, Falls Church, VA 22042-3307Phone(703) 776-4401Fax(703) 776-7113Mailing LocationMailing Address3300 Gallows Rd, Falls Church, VA 22042-3307Phone(703) 776-4401Fax(703) 776-7113Provider TaxonomiesCodeDescriptionLicenseCode207R00000XPrimaryDescriptionInternal MedicineAllopathic & Osteopathic PhysiciansLicense0101251159VirginiaCode207R00000XDescriptionInternal MedicineAllopathic & Osteopathic PhysiciansLicense003711Georgia