Healthcare Provider Details

I. General information

NPI: 1073757662
Provider Name (Legal Business Name): ACTIVE MEDICAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2009
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3930 PENDER DR STE 230
FAIRFAX VA
22030-0992
US

IV. Provider business mailing address

4879 MAYDE CT
FAIRFAX VA
22030-6618
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 Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101237882
License Number StateVA

VIII. Authorized Official

Name: KHAIRUNNISA MASOOD
Title or Position: OWNER
Credential: MD
Phone: 703-987-8165