Healthcare Provider Details

I. General information

NPI: 1720471824
Provider Name (Legal Business Name): HAYDAR AL-DABBAGH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2015
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8260 ATLEE RD
MECHANICSVILLE VA
23116-1844
US

IV. Provider business mailing address

11767 TRIPLE NOTCH TER
HENRICO VA
23233-1193
US

V. Phone/Fax

Practice location:
  • Phone: 804-764-6300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101270961
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberDR.0073746
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: