Healthcare Provider Details

I. General information

NPI: 1669853586
Provider Name (Legal Business Name): PALLABI GUHA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2015
Last Update Date: 06/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 GALLOWS RD
FALLS CHURCH VA
22042-3307
US

IV. Provider business mailing address

3300 GALLOWS RD
FALLS CHURCH VA
22042-3307
US

V. Phone/Fax

Practice location:
  • Phone: 703-776-6652
  • Fax: 703-776-4323
Mailing address:
  • Phone: 703-776-6652
  • Fax: 703-776-4323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0116028204
License Number StateVI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: