=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679710776
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEENA KOSANDAL M.D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2009
-----------------------------------------------------
Last Update Date | 06/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12255 FAIR LAKES PKWY
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22033-3952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-934-5700
-----------------------------------------------------
Fax | 703-934-5839
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12255 FAIR LAKES PKWY
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22033-3952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-934-5700
-----------------------------------------------------
Fax | 703-934-5839
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | D0069166
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------