Provider Demographics
NPI:1972509735
Name:CHANTILLY WALK-IN CLINIC
Entity Type:Organization
Organization Name:CHANTILLY WALK-IN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:NAZAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-631-0791
Mailing Address - Street 1:PO BOX 221226
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20153-1226
Mailing Address - Country:US
Mailing Address - Phone:703-631-0791
Mailing Address - Fax:703-968-4227
Practice Address - Street 1:13037 LEE JACKSON HWY
Practice Address - Street 2:STE D
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2004
Practice Address - Country:US
Practice Address - Phone:703-631-0791
Practice Address - Fax:703-968-4227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101036326261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA292549OtherB/C PROVIDER #
VAE13603Medicare UPIN
VAG01029Medicare ID - Type Unspecified