Provider Demographics
NPI:1295078848
Name:SHASTI, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SHASTI
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46090 LAKE CENTER PLZ STE 102
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20165-5877
Mailing Address - Country:US
Mailing Address - Phone:703-774-3132
Mailing Address - Fax:703-683-7801
Practice Address - Street 1:21351 GENTRY DR STE 125
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20166-8511
Practice Address - Country:US
Practice Address - Phone:703-774-3132
Practice Address - Fax:703-683-7801
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-02
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101266855207X00000X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100527830Medicaid