Provider Demographics
NPI:1770943565
Name:VIRGINIA RETINA SPECIALISTS
Entity type:Organization
Organization Name:VIRGINIA RETINA SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REP/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KHURRAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:MALIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-288-9001
Mailing Address - Street 1:6400 ARLINGTON BLVD.
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-2349
Mailing Address - Country:US
Mailing Address - Phone:703-288-9001
Mailing Address - Fax:703-288-5169
Practice Address - Street 1:6400 ARLINGTON BLVD.
Practice Address - Street 2:SUITE 600
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-2349
Practice Address - Country:US
Practice Address - Phone:703-288-9001
Practice Address - Fax:703-288-5169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-07
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA207WX0107X, 207WX0108X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Multi-Specialty
No207WX0108XAllopathic & Osteopathic PhysiciansOphthalmologyUveitis and Ocular Inflammatory DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD634503400Medicaid
DC057748500Medicaid
VA1770943565Medicaid
DC057748500Medicaid