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General NPI Number Information
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NPI Number | 1972509735
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Entity Type | Organization
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Legal Business Name | CHANTILLY WALK-IN CLINIC
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Dates
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Enumeration Date | 06/24/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 13037 LEE JACKSON HWY STE D
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City | FAIRFAX
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State | VA
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Zip | 22033-2004
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Country | US
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Telephone | 703-631-0791
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Fax | 703-968-4227
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Provider Business Mailing Address
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Address Line | PO BOX 221226
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City | CHANTILLY
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State | VA
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Zip | 20153-1226
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Country | US
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Telephone | 703-631-0791
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Fax | 703-968-4227
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. SAMIR NAZAM
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Credential | M.D.
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Telephone | 703-631-0791
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 0101036326
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License Number State | VA
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