Healthcare Provider Details

I. General information

NPI: 1598950818
Provider Name (Legal Business Name): JYOTSNA HEBBAR SHAH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JYOTSNA SHAH MD

II. Dates (important events)

Enumeration Date: 09/10/2007
Last Update Date: 09/16/2022
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20955 PROFESSIONAL PLAZA SUITE 200
ASHBURN VA
20147-3405
US

IV. Provider business mailing address

224-D CORNWALL ST. NW SUITE 403
LEESBURG VA
20176-2704
US

V. Phone/Fax

Practice location:
  • Phone: 703-729-7652
  • Fax: 703-729-8746
Mailing address:
  • Phone: 703-737-6010
  • Fax: 703-443-8643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101241988
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: