Basic Information
| Provider Information | |||||||||
| NPI: | 1124100755 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHOUDHARY | ||||||||
| FirstName: | IMTIAZ | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 17334 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212971334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7034436717 | ||||||||
| FaxNumber: | 7034438643 | ||||||||
| Practice Location | |||||||||
| Address1: | 6226 OLD FRANCONIA RD | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223103404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033135060 | ||||||||
| FaxNumber: | 7033139446 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2006 | ||||||||
| LastUpdateDate: | 12/03/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 0101054520 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 401849400 | 05 | MD | MEDICAID | 010020751 | 05 | VA | MEDICAID | 017113900 | 05 | DC | MEDICAID |