Healthcare Provider Details

I. General information

NPI: 1912403734
Provider Name (Legal Business Name): KOVOSH DASTAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 04/17/2025
Certification Date: 04/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 CAMPUS BLVD STE 410
WINCHESTER VA
22601-2872
US

IV. Provider business mailing address

220 CAMPUS BLVD STE 320
WINCHESTER VA
22601-2889
US

V. Phone/Fax

Practice location:
  • Phone: 540-450-2339
  • Fax: 540-450-2333
Mailing address:
  • Phone: 540-536-5100
  • Fax: 540-536-0235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number0101275853
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: