Healthcare Provider Details

I. General information

NPI: 1336169598
Provider Name (Legal Business Name): MUBARIK KHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 02/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3930 PENDER DR SUITE 230
FAIRFAX VA
22030-0985
US

IV. Provider business mailing address

3930 PENDER DR SUITE 230
FAIRFAX VA
22030-0985
US

V. Phone/Fax

Practice location:
  • Phone: 703-620-6221
  • Fax: 703-620-6628
Mailing address:
  • Phone: 703-620-6221
  • Fax: 703-620-6628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0101059082
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: