Healthcare Provider Details

I. General information

NPI: 1972509735
Provider Name (Legal Business Name): CHANTILLY WALK-IN CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13037 LEE JACKSON HWY STE D
FAIRFAX VA
22033-2004
US

IV. Provider business mailing address

PO BOX 221226
CHANTILLY VA
20153-1226
US

V. Phone/Fax

Practice location:
  • Phone: 703-631-0791
  • Fax: 703-968-4227
Mailing address:
  • Phone: 703-631-0791
  • Fax: 703-968-4227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number0101036326
License Number StateVA

VIII. Authorized Official

Name: DR. SAMIR NAZAM
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 703-631-0791