Provider Demographics
NPI:1124211487
Name:EDNAN MUSHTAQ MD PC
Entity Type:Organization
Organization Name:EDNAN MUSHTAQ MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:EDNAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSHTAQ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-448-0005
Mailing Address - Street 1:6845 ELM ST
Mailing Address - Street 2:SUITE 303
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-6007
Mailing Address - Country:US
Mailing Address - Phone:703-448-0005
Mailing Address - Fax:703-448-0808
Practice Address - Street 1:6845 ELM ST
Practice Address - Street 2:SUITE 303
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-6007
Practice Address - Country:US
Practice Address - Phone:703-448-0005
Practice Address - Fax:703-448-0808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101055447207Y00000X, 207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006503535Medicaid
VAG01201Medicare PIN
VA006503535Medicaid