Provider Demographics
NPI:1568574200
Name:PREMKUMAR, AHALYA (MD)
Entity Type:Individual
Prefix:
First Name:AHALYA
Middle Name:
Last Name:PREMKUMAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 WILLIAMS DRIVE
Mailing Address - Street 2:STE 200
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031
Mailing Address - Country:US
Mailing Address - Phone:703-641-9133
Mailing Address - Fax:703-280-5098
Practice Address - Street 1:21351 RIDGETOP CIRCLE
Practice Address - Street 2:STE 100
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20166
Practice Address - Country:US
Practice Address - Phone:703-641-9133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00650702085R0202X
VA01010442162085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology