Healthcare Provider Details

I. General information

NPI: 1760449748
Provider Name (Legal Business Name): AHMED SHAHAB-UDDIN M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 01/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16011 KAIROS RD SUITE 100
SOUTH CHESTERFIELD VA
23834-5207
US

IV. Provider business mailing address

16011 KAIROS RD SUITE 100
SOUTH CHESTERFIELD VA
23834-5207
US

V. Phone/Fax

Practice location:
  • Phone: 804-520-2600
  • Fax:
Mailing address:
  • Phone: 804-520-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number56041
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: