Provider Demographics
NPI:1073831780
Name:FAIR OAKS PODIATRY AND SPORTS
Entity Type:Organization
Organization Name:FAIR OAKS PODIATRY AND SPORTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ZAKEE
Authorized Official - Middle Name:OMAR
Authorized Official - Last Name:SHABAZZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:703-865-6783
Mailing Address - Street 1:3620 JOSEPH SIEWICK DR
Mailing Address - Street 2:303
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-1756
Mailing Address - Country:US
Mailing Address - Phone:703-865-6783
Mailing Address - Fax:703-865-6784
Practice Address - Street 1:3620 JOSEPH SIEWICK DR
Practice Address - Street 2:303
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1756
Practice Address - Country:US
Practice Address - Phone:703-865-6783
Practice Address - Fax:703-865-6784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-06
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103300961213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA159262Medicare PIN