Provider Demographics
NPI:1174576581
Name:KHAYATA, ISSAM (MD)
Entity type:Individual
Prefix:
First Name:ISSAM
Middle Name:
Last Name:KHAYATA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2521
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20195-0521
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 PIDGEON HILL DR
Practice Address - Street 2:STE 205
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20165-6134
Practice Address - Country:US
Practice Address - Phone:508-334-3271
Practice Address - Fax:508-856-5911
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101259392207L00000X, 207RC0200X, 207LP2900X
MA212629207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0179043Medicaid
VA30015831410003Medicaid
MA0179043Medicaid