Provider Demographics
NPI:1275619363
Name:AWAN, MUSHTAQ AHMAD
Entity Type:Individual
Prefix:MR
First Name:MUSHTAQ
Middle Name:AHMAD
Last Name:AWAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7115 LEESBURG PIKE
Mailing Address - Street 2:SUITE # 315
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22043-2367
Mailing Address - Country:US
Mailing Address - Phone:703-522-8840
Mailing Address - Fax:
Practice Address - Street 1:7115 LEESBURG PIKE
Practice Address - Street 2:SUITE # 315
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22043-2367
Practice Address - Country:US
Practice Address - Phone:703-522-8840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101040126208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007301006Medicaid
VA007301006Medicaid
B66741Medicare UPIN