Healthcare Provider Details

I. General information

NPI: 1114306677
Provider Name (Legal Business Name): NOUSHIN JAZEBI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2015
Last Update Date: 06/01/2020
Certification Date: 06/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BG 10-CRC RM 7-5680 MSC 1404 10 CENTER DRIVE
BETHESDA MD
20892-1404
US

IV. Provider business mailing address

BG 10-CRC RM 7-5680 MSC 1404 10 CENTER DRIVE
BETHESDA MD
20892-1404
US

V. Phone/Fax

Practice location:
  • Phone: 301-496-5295
  • Fax:
Mailing address:
  • Phone: 301-496-5295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberBP10052633
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberBP20057918
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberMD468110
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberBP20057918
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: