Healthcare Provider Details

I. General information

NPI: 1619971264
Provider Name (Legal Business Name): SUBASH B. BAZAZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 07/14/2023
Certification Date: 07/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44035 RIVERSIDE PKWY STE 400
LEESBURG VA
20176-8260
US

IV. Provider business mailing address

2901 TELESTAR CT. #300
FALLS CHURCH VA
22042-1261
US

V. Phone/Fax

Practice location:
  • Phone: 703-858-5421
  • Fax: 703-858-9573
Mailing address:
  • Phone: 703-591-1688
  • Fax: 703-591-1445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number0101232467
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: