Individual
MOHAMMAD SHAHIM FORMOLY
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
CSA
Contact information
Practice address
12011 LEE JACKSON MEMORIAL HWY STE 501, FAIRFAX, VA 22033
(703) 349-1379
Mailing address
PO BOX 221135, CHANTILLY, VA 20153-1135
(703) 349-1379
Taxonomy
Speciality
Code
Description
License number
State
246ZC0007X
Surgical Assistant
Primary
4160
—
Other
Enumeration date
08/15/2014
Last updated
09/06/2018
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