Healthcare Provider Details

I. General information

NPI: 1184269714
Provider Name (Legal Business Name): SKIN INSTITUTE OF VIRGINIA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2019
Last Update Date: 11/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19455 DEERFIELD AVE STE 311
LANSDOWNE VA
20176-8102
US

IV. Provider business mailing address

7712 FALSTAFF RD
MC LEAN VA
22102-2723
US

V. Phone/Fax

Practice location:
  • Phone: 703-723-9751
  • Fax:
Mailing address:
  • Phone: 703-615-6569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: FARHAAD RAHMAN RIYAZ
Title or Position: CEO
Credential: MD
Phone: 703-615-6569