Healthcare Provider Details

I. General information

NPI: 1285605030
Provider Name (Legal Business Name): FIRDAUS DASTOOR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 BRAEBURN DR
SALEM VA
24153-7357
US

IV. Provider business mailing address

1802 BRAEBURN DR
SALEM VA
24153-7357
US

V. Phone/Fax

Practice location:
  • Phone: 540-772-5970
  • Fax: 540-725-4542
Mailing address:
  • Phone: 540-772-5970
  • Fax: 540-725-4542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number0101237493
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: