Healthcare Provider Details

I. General information

NPI: 1295812899
Provider Name (Legal Business Name): KHOSROW DAVACHI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7700 OLD BRANCH AVE STE D203
CLINTON MD
20735-1611
US

IV. Provider business mailing address

7700 OLD BRANCH AVE STE D203
CLINTON MD
20735-1611
US

V. Phone/Fax

Practice location:
  • Phone: 301-868-7121
  • Fax: 301-868-7968
Mailing address:
  • Phone: 301-868-7121
  • Fax: 301-868-7968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberD0025640
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMD8172
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: