Provider Demographics
NPI:1538156740
Name:WASIMUDDIN, KHALID (MD)
Entity type:Individual
Prefix:DR
First Name:KHALID
Middle Name:
Last Name:WASIMUDDIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15768 BEAU RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-1028
Mailing Address - Country:US
Mailing Address - Phone:703-499-9966
Mailing Address - Fax:703-499-8515
Practice Address - Street 1:14904 RICHMOND HWY STE 302
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3908
Practice Address - Country:US
Practice Address - Phone:703-499-9966
Practice Address - Fax:703-499-8515
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-03
Last Update Date:2023-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101051384207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5843758Medicaid
VA5800871Medicaid
VAF83601OtherUPIN