Healthcare Provider Details

I. General information

NPI: 1144214958
Provider Name (Legal Business Name): ASHUTOSH B DIWAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

493 BLACKWELL RD SUITE 202
WARRENTON VA
20186-2639
US

IV. Provider business mailing address

PO BOX 748613
ATLANTA GA
30384-8613
US

V. Phone/Fax

Practice location:
  • Phone: 540-347-4400
  • Fax: 540-341-4766
Mailing address:
  • Phone: 434-295-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number2023001690
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101229792
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0429558
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: