Healthcare Provider Details

I. General information

NPI: 1245201045
Provider Name (Legal Business Name): GHULAM DASTIGIR QURESHI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 09/25/2020
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6605 W BROAD ST STE A
RICHMOND VA
23230-1714
US

IV. Provider business mailing address

7202 GLEN FOREST DR C/O VIRGINIA CANCER INSTITUTE SUITE 200
RICHMOND VA
23226-3781
US

V. Phone/Fax

Practice location:
  • Phone: 804-287-3000
  • Fax: 804-673-2731
Mailing address:
  • Phone: 804-673-0134
  • Fax: 804-673-1796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number0101021014
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number541436644
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: