Healthcare Provider Details

I. General information

NPI: 1346348075
Provider Name (Legal Business Name): NADER TAVAKOLI PA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/25/2021
Certification Date: 08/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 MEDICAL CENTER DRIVE SUITE 230-F
LARGO MD
20774
US

IV. Provider business mailing address

626 ADMIRAL DR SUITE C #235
ANNAPOLIS MD
21401-2151
US

V. Phone/Fax

Practice location:
  • Phone: 301-352-7118
  • Fax: 301-352-7779
Mailing address:
  • Phone: 301-352-7118
  • Fax: 301-352-7779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberD41978
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. NADER TAVAKOLI-JALILI
Title or Position: PRESIDENT
Credential: MD
Phone: 301-352-7118