Healthcare Provider Details

I. General information

NPI: 1538779509
Provider Name (Legal Business Name): BLOSSOMING MINDS PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2020
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10380 OLD COLUMBIA RD STE 100
COLUMBIA MD
21046-2005
US

IV. Provider business mailing address

10380 OLD COLUMBIA RD STE 100
COLUMBIA MD
21046-2005
US

V. Phone/Fax

Practice location:
  • Phone: 410-656-4775
  • Fax:
Mailing address:
  • Phone: 240-506-0739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KEYVAN RAFEI
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 240-506-0739