Healthcare Provider Details

I. General information

NPI: 1639129091
Provider Name (Legal Business Name): EDNAN MUSHTAQ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 08/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6845 ELM STREET SUITE 303
MCLEAN VA
22101
US

IV. Provider business mailing address

6845 ELM STREET SUITE 303
MCLEAN VA
22101
US

V. Phone/Fax

Practice location:
  • Phone: 703-448-0005
  • Fax: 703-448-0808
Mailing address:
  • Phone: 703-448-0005
  • Fax: 703-448-0808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number0101055447
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number0101055447
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: