Provider Demographics
NPI:1639129091
Name:MUSHTAQ, EDNAN (MD)
Entity Type:Individual
Prefix:
First Name:EDNAN
Middle Name:
Last Name:MUSHTAQ
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 1:6845 ELM STREET
Mailing Address - Street 2:SUITE 303
Mailing Address - City:MCLEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101
Mailing Address - Country:US
Mailing Address - Phone:703-448-0005
Mailing Address - Fax:703-448-0808
Practice Address - Street 1:6845 ELM STREET
Practice Address - Street 2:SUITE 303
Practice Address - City:MCLEAN
Practice Address - State:VA
Practice Address - Zip Code:22101
Practice Address - Country:US
Practice Address - Phone:703-448-0005
Practice Address - Fax:703-448-0808
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101055447207YX0905X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G01201Medicare PIN
F89572Medicare UPIN