Healthcare Provider Details

I. General information

NPI: 1780408583
Provider Name (Legal Business Name): BASHIR AHMAD KHADIM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2024
Last Update Date: 11/09/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N HENRY ST APT 705
ALEXANDRIA VA
22314-2074
US

IV. Provider business mailing address

900 N HENRY ST APT 705
ALEXANDRIA VA
22314-2074
US

V. Phone/Fax

Practice location:
  • Phone: 443-779-9459
  • Fax:
Mailing address:
  • Phone: 443-779-9459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: