Provider Demographics
NPI:1598950818
Name:SHAH, JYOTSNA HEBBAR (MD)
Entity type:Individual
Prefix:
First Name:JYOTSNA
Middle Name:HEBBAR
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JYOTSNA
Other - Middle Name:
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:224-D CORNWALL ST. NW SUITE 403
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:20955 PROFESSIONAL PLAZA SUITE 200
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-3405
Practice Address - Country:US
Practice Address - Phone:703-729-7652
Practice Address - Fax:703-729-8746
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101241988208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1598950818Medicaid
VA014890L19Medicare PIN
VAC06319Medicare PIN