Provider Demographics
NPI:1548296817
Name:SHABAZZ, DWANA RASHAD (MD)
Entity type:Individual
Prefix:
First Name:DWANA
Middle Name:RASHAD
Last Name:SHABAZZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DWANA
Other - Middle Name:RASHAD
Other - Last Name:LYNCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12011 LEE JACKSON MEMORIAL HWY SUITE 440
Mailing Address - Street 2:SUITE 303
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033
Mailing Address - Country:US
Mailing Address - Phone:703-865-6801
Mailing Address - Fax:703-865-6784
Practice Address - Street 1:12011 LEE JACKSON MEMORIAL HWY STE 440
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-3335
Practice Address - Country:US
Practice Address - Phone:703-865-6801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101240235174400000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
I64543Medicare UPIN