Provider Demographics
NPI:1699032904
Name:OSHIRAK, KIMBERLY TYLER (MD)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:TYLER
Last Name:OSHIRAK
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 1:9001 DIGGES ROAD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110
Mailing Address - Country:US
Mailing Address - Phone:703-392-5437
Mailing Address - Fax:703-392-0176
Practice Address - Street 1:9001 DIGGES ROAD
Practice Address - Street 2:SUITE 106
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110
Practice Address - Country:US
Practice Address - Phone:703-392-5437
Practice Address - Fax:703-392-0176
Is Sole Proprietor?:No
Enumeration Date:2012-04-12
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101102698208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1699032904Medicaid