Provider Demographics
NPI:1295760510
Name:DULLES FAMILY MEDICINE P.C.
Entity type:Organization
Organization Name:DULLES FAMILY MEDICINE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF PRACTICE C CORPORATION
Authorized Official - Prefix:
Authorized Official - First Name:SHAMIM
Authorized Official - Middle Name:AKHTAR
Authorized Official - Last Name:IMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-471-0800
Mailing Address - Street 1:504 ELDEN ST # 3
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4741
Mailing Address - Country:US
Mailing Address - Phone:703-471-0800
Mailing Address - Fax:703-471-1332
Practice Address - Street 1:504 ELDEN ST # 3
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4741
Practice Address - Country:US
Practice Address - Phone:703-471-0800
Practice Address - Fax:703-471-1332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101046800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
064662Medicare ID - Type Unspecified
F34514Medicare UPIN