Healthcare Provider Details

I. General information

NPI: 1649540550
Provider Name (Legal Business Name): ESSAM A. FAWZY SA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2012
Last Update Date: 09/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12011 LEE JACKSON HWY STE 501
FAIRFAX VA
22033-3315
US

IV. Provider business mailing address

12011 LEE JACKSON HWY STE 501
FAIRFAX VA
22033-3315
US

V. Phone/Fax

Practice location:
  • Phone: 703-259-7027
  • Fax:
Mailing address:
  • Phone: 703-259-7027
  • Fax: 703-591-0005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number04-137
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: