Provider Demographics
NPI:1356548366
Name:FATEMA, KANIZ (MD)
Entity type:Individual
Prefix:
First Name:KANIZ
Middle Name:
Last Name:FATEMA
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 1:9527 PARSONAGE LN
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-2776
Mailing Address - Country:US
Mailing Address - Phone:703-646-5494
Mailing Address - Fax:
Practice Address - Street 1:12581 MILSTEAD WAY STE 103
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-5446
Practice Address - Country:US
Practice Address - Phone:703-437-6060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101241486261QU0200X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care