Healthcare Provider Details

I. General information

NPI: 1689802647
Provider Name (Legal Business Name): ANDREA KASSIM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4375 FAIR LAKES CT FL 3
FAIRFAX VA
22033-4234
US

IV. Provider business mailing address

9230 OLD KEENE MILL RD # 1036
BURKE VA
22015-4201
US

V. Phone/Fax

Practice location:
  • Phone: 571-432-2600
  • Fax:
Mailing address:
  • Phone: 571-432-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number0101272756
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number266015
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number0101272756
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number25MA09182700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: