Healthcare Provider Details

I. General information

NPI: 1912058736
Provider Name (Legal Business Name): BASSEMA A ANTABLI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12255 FAIR LAKES PARKWAY
FAIRFAX VA
22033
US

IV. Provider business mailing address

2101 EAST JEFFERSON STREET KAISER PERMANENTE, PPQA, 6 WEST
ROCKVILLE MD
20874
US

V. Phone/Fax

Practice location:
  • Phone: 703-934-5700
  • Fax: 703-934-5778
Mailing address:
  • Phone: 301-816-6660
  • Fax: 301-816-6308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberMD30549
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberD54763
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number0101053020
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: