Provider Demographics
NPI:1396704581
Name:FAROOQ, MOHAMMAD (MD)
Entity type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:FAROOQ
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 1:12712 BAY HILL DR
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23836-2680
Mailing Address - Country:US
Mailing Address - Phone:804-590-6750
Mailing Address - Fax:804-681-0782
Practice Address - Street 1:1714 E HUNDRED RD STE 101
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23836-3310
Practice Address - Country:US
Practice Address - Phone:804-590-6750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101055927207RP1001X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06778OtherGROUP PTAN
VACI3965OtherMEDICARE RR GROUP
VA005811074Medicaid
VA290010581OtherMEDICARE RAILROAD
C05898OtherMEDICARE GROUP NUMBER
VA290010581OtherMEDICARE RAILROAD
VA005811074Medicaid