Healthcare Provider Details

I. General information

NPI: 1457188518
Provider Name (Legal Business Name): MR. JAMAL UD DIN KHATTAK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2024
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6569 EDSALL RD
SPRINGFIELD VA
22151-4414
US

IV. Provider business mailing address

6569 EDSALL RD
SPRINGFIELD VA
22151-4414
US

V. Phone/Fax

Practice location:
  • Phone: 571-222-5829
  • Fax: 571-351-6081
Mailing address:
  • Phone: 571-222-5829
  • Fax: 571-351-6081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: