Healthcare Provider Details

I. General information

NPI: 1164839601
Provider Name (Legal Business Name): IHAB MASSAD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2014
Last Update Date: 07/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5597 SEMINARY RD APT 2417S
FALLS CHURCH VA
22041-2923
US

IV. Provider business mailing address

5597 SEMINARY RD APT 2417S
FALLS CHURCH VA
22041-2923
US

V. Phone/Fax

Practice location:
  • Phone: 202-415-5891
  • Fax:
Mailing address:
  • Phone: 202-415-5891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number0116026982
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberP29964
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberMTL002518
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: