Provider Demographics
NPI:1053592337
Name:CHANTILLY FAMILY PRACTICE
Entity type:Organization
Organization Name:CHANTILLY FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJESH
Authorized Official - Middle Name:N
Authorized Official - Last Name:MEHRA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:703-968-7277
Mailing Address - Street 1:4437 BROOKFIELD CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-2122
Mailing Address - Country:US
Mailing Address - Phone:703-968-7277
Mailing Address - Fax:703-968-5644
Practice Address - Street 1:4437 BROOKFIELD CORPORATE DR
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-2122
Practice Address - Country:US
Practice Address - Phone:703-968-7277
Practice Address - Fax:703-968-5644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102033582261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD18017Medicare UPIN