Provider Demographics
NPI:1497749055
Name:SHINAISHIN, AHMED TARIK (MD)
Entity Type:Individual
Prefix:DR
First Name:AHMED
Middle Name:TARIK
Last Name:SHINAISHIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7500 IRON BAR LN STE 120
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155-3603
Mailing Address - Country:US
Mailing Address - Phone:703-753-6772
Mailing Address - Fax:888-972-4515
Practice Address - Street 1:7500 IRON BAR LN STE 120
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-3603
Practice Address - Country:US
Practice Address - Phone:703-753-6772
Practice Address - Fax:888-972-4515
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2014-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0058963208000000X
VA0101239493208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDH33950Medicaid