Healthcare Provider Details

I. General information

NPI: 1467651489
Provider Name (Legal Business Name): TABASSUM SUBUHI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2007
Last Update Date: 06/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2149 ELECTRIC RD
ROANOKE VA
24018-1975
US

IV. Provider business mailing address

PO BOX 4127
ROANOKE VA
24015-0127
US

V. Phone/Fax

Practice location:
  • Phone: 540-725-7555
  • Fax: 540-725-7553
Mailing address:
  • Phone: 540-981-9394
  • Fax: 540-344-7154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number0101239659
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: