Healthcare Provider Details

I. General information

NPI: 1437689478
Provider Name (Legal Business Name): MEHDI TAVAKOLI DASTJERDI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 10/27/2022
Certification Date: 10/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 PENNSYLVANIA AVE NW
WASHINGTON DC
20037-3201
US

IV. Provider business mailing address

P.O. BOX 830941 MSC# 559
BIRMINGHAM AL
35283
US

V. Phone/Fax

Practice location:
  • Phone: 202-741-2800
  • Fax: 202-741-2805
Mailing address:
  • Phone: 205-325-8536
  • Fax: 205-325-8270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberHSE24976
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberL.5059SP
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: