Provider Demographics
NPI:1083376230
Name:STAMBOULI, MOHAMED AMINE (CSA)
Entity Type:Individual
Prefix:
First Name:MOHAMED
Middle Name:AMINE
Last Name:STAMBOULI
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5771 COAKLEY DR
Mailing Address - Street 2:
Mailing Address - City:KING GEORGE
Mailing Address - State:VA
Mailing Address - Zip Code:22485-2457
Mailing Address - Country:US
Mailing Address - Phone:202-749-1404
Mailing Address - Fax:
Practice Address - Street 1:5771 COAKLEY DR
Practice Address - Street 2:
Practice Address - City:KING GEORGE
Practice Address - State:VA
Practice Address - Zip Code:22485-2457
Practice Address - Country:US
Practice Address - Phone:202-749-1404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZX2200X
VA0136000242246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No246ZX2200XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherOrthopedic Assistant