=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174329445
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALLAH DAD KHAN MARUFKHAIL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2025
-----------------------------------------------------
Last Update Date | 02/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13710 ST FRANCIS BLVD
-----------------------------------------------------
City | MIDLOTHIAN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23114-3267
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-594-3050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1728 HUDGINS FARM CIR
-----------------------------------------------------
City | FREDERICKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22408-4178
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-261-8302
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246ZC0007X
-----------------------------------------------------
Taxonomy Name | Surgical Assistant
-----------------------------------------------------
License Number | 0136000951
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------