Provider Demographics
NPI:1619971264
Name:BAZAZ, SUBASH B (MD)
Entity type:Individual
Prefix:
First Name:SUBASH
Middle Name:B
Last Name:BAZAZ
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 1:2901 TELESTAR CT.
Mailing Address - Street 2:#300
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-1261
Mailing Address - Country:US
Mailing Address - Phone:703-591-1688
Mailing Address - Fax:703-591-1445
Practice Address - Street 1:44035 RIVERSIDE PKWY
Practice Address - Street 2:STE 400
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-8260
Practice Address - Country:US
Practice Address - Phone:703-858-5421
Practice Address - Fax:703-858-9573
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101232467207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC060066479OtherRAILROAD MEDICARE DC #
VA1619971264Medicaid
DC034162800Medicaid
MD487504400Medicaid
VA060066480OtherRAILROAD MEDICARE VA #
VAH53516Medicare UPIN
MD487504400Medicaid
DC008780C42Medicare PIN
DC008780C42Medicare PIN