Healthcare Provider Details

I. General information

NPI: 1083376230
Provider Name (Legal Business Name): MOHAMED AMINE STAMBOULI CSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2021
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5771 COAKLEY DR
KING GEORGE VA
22485-2457
US

IV. Provider business mailing address

5771 COAKLEY DR
KING GEORGE VA
22485-2457
US

V. Phone/Fax

Practice location:
  • Phone: 202-749-1404
  • Fax:
Mailing address:
  • Phone: 202-749-1404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number0136000242
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code246ZX2200X
TaxonomyOrthopedic Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: