1174576581 NPI number — ISSAM KHAYATA MD

Table of content: ISSAM KHAYATA MD (NPI 1174576581)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174576581 NPI number — ISSAM KHAYATA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KHAYATA
Provider First Name:
ISSAM
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174576581
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2521
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RESTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20195-0521
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 PIDGEON HILL DR
Provider Second Line Business Practice Location Address:
STE 205
Provider Business Practice Location Address City Name:
STERLING
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20165-6134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-334-3271
Provider Business Practice Location Address Fax Number:
508-856-5911
Provider Enumeration Date:
05/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  0101259392 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: 212629 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0200X , with the licence number: 0101259392 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X , with the licence number: 0101259392 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0179043 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 30015831410003 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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