Healthcare Provider Details

I. General information

NPI: 1447308689
Provider Name (Legal Business Name): ASHISH GAJANAN SHANBHAG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2007
Last Update Date: 07/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14605 POTOMAC BRANCH DR STE 100
WOODBRIDGE VA
22191
US

IV. Provider business mailing address

PO BOX 6012
SPARTANBURG SC
29304-6012
US

V. Phone/Fax

Practice location:
  • Phone: 703-738-4371
  • Fax:
Mailing address:
  • Phone: 864-278-6006
  • Fax: 864-278-6007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number19477
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number19477
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number19477
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number19477
License Number StateSC
# 5
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number0101252651
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: