Healthcare Provider Details

I. General information

NPI: 1689746166
Provider Name (Legal Business Name): MANNUL WAHAB MUHIUDDIN AHMED MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13893 REMBRANDT WAY
CHANTILLY VA
20151-3265
US

IV. Provider business mailing address

2101 EAST JEFFERSON STREET PPQA MEDICARE COMPLIANCE UNIT 6 WEST ATTN THERESA BROOK
ROCKVILLE MD
20852-4908
US

V. Phone/Fax

Practice location:
  • Phone: 703-403-0460
  • Fax: 703-490-7650
Mailing address:
  • Phone: 301-816-6660
  • Fax: 301-816-6308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0072076
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD039289
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101055858
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: