Healthcare Provider Details

I. General information

NPI: 1164868782
Provider Name (Legal Business Name): PRASANN VACHHANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2013
Last Update Date: 05/05/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3299 WOODBURN RD STE 110
ANNANDALE VA
22003-7310
US

IV. Provider business mailing address

2722 MERRILEE DR STE 230
FAIRFAX VA
22031-4400
US

V. Phone/Fax

Practice location:
  • Phone: 703-698-4488
  • Fax:
Mailing address:
  • Phone: 703-698-4483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25MA10511200
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberD0082184
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101264582
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: