Healthcare Provider Details

I. General information

NPI: 1164448577
Provider Name (Legal Business Name): FAIRFAX GASTROENTEROLOGY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 JOSEPH SIEWICK DR STE 205B
FAIRFAX VA
22033-1712
US

IV. Provider business mailing address

PO BOX 220037
CHANTILLY VA
20153-0037
US

V. Phone/Fax

Practice location:
  • Phone: 703-620-0688
  • Fax: 703-620-6628
Mailing address:
  • Phone: 703-620-0688
  • Fax: 703-620-6628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateVA

VIII. Authorized Official

Name: WASEEM AZIZ
Title or Position: PRESIDENT
Credential: MD
Phone: 703-620-0688