Provider Demographics
NPI:1518573534
Name:DULLES PAIN & FUNCTIONAL MEDICINE
Entity Type:Organization
Organization Name:DULLES PAIN & FUNCTIONAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ISSAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAYATA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-884-8400
Mailing Address - Street 1:PO BOX 2521
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20195-0521
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 PIDGEON HILL DR STE 205
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20165-6134
Practice Address - Country:US
Practice Address - Phone:703-884-8400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-16
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care MedicineGroup - Multi-Specialty