Healthcare Provider Details

I. General information

NPI: 1952942666
Provider Name (Legal Business Name): REZA MOGHADDASNIA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2019
Last Update Date: 10/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 OLD GEORGETOWN RD
BETHESDA MD
20814-1422
US

IV. Provider business mailing address

2303 FOX FIRE CT
RESTON VA
20191-4605
US

V. Phone/Fax

Practice location:
  • Phone: 301-896-3100
  • Fax:
Mailing address:
  • Phone: 703-376-1547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberC0007346
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: