Healthcare Provider Details

I. General information

NPI: 1669091211
Provider Name (Legal Business Name): VISHAL DASARI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2020
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6849 OLD DOMINION DR STE 300
MC LEAN VA
22101-3791
US

IV. Provider business mailing address

6201 GREENLEIGH AVE DEPT OF
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 571-730-6262
  • Fax:
Mailing address:
  • Phone: 617-414-6239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD500002445
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101279575
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: