Healthcare Provider Details

I. General information

NPI: 1821951450
Provider Name (Legal Business Name): EBADULLAH WAHIDI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
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

PO BOX 221135
CHANTILLY VA
20153-1135
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number0136001073
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: