Healthcare Provider Details

I. General information

NPI: 1699352856
Provider Name (Legal Business Name): KHUSHALI SHAH MD, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3998 FAIR RIDGE DR STE 105
FAIRFAX VA
22033-2980
US

IV. Provider business mailing address

3998 FAIR RIDGE DR STE 105
FAIRFAX VA
22033-2980
US

V. Phone/Fax

Practice location:
  • Phone: 571-349-2191
  • Fax: 571-349-2211
Mailing address:
  • Phone: 571-349-2191
  • Fax: 571-349-2211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA202221
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207WX0120X
TaxonomyCornea and External Diseases Specialist Physician
License Number0101289113
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: