Healthcare Provider Details

I. General information

NPI: 1124558408
Provider Name (Legal Business Name): DIANA SHUSTAROVICH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2017
Last Update Date: 02/08/2022
Certification Date: 02/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 TOWN CENTER PKWY STE 650
RESTON VA
20190-3300
US

IV. Provider business mailing address

3401 SHERMAN AVE NW UNIT A
WASHINGTON DC
20010-3600
US

V. Phone/Fax

Practice location:
  • Phone: 703-955-5978
  • Fax:
Mailing address:
  • Phone: 347-247-8337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0101274112
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberD0092078
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: