Healthcare Provider Details

I. General information

NPI: 1922356054
Provider Name (Legal Business Name): FAIRFAX LOUDOUN OBGYN, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2012
Last Update Date: 10/13/2023
Certification Date: 10/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3930 PENDER DR STE 60
FAIRFAX VA
22030-0991
US

IV. Provider business mailing address

3930 PENDER DR STE 60
FAIRFAX VA
22030-0991
US

V. Phone/Fax

Practice location:
  • Phone: 571-249-0717
  • Fax:
Mailing address:
  • Phone: 571-249-0717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SHAWANA MUFTI
Title or Position: OWNER
Credential: MD
Phone: 571-249-0717