Healthcare Provider Details

I. General information

NPI: 1265502389
Provider Name (Legal Business Name): BAHRAM PISHDAD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 12/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 LARGO RD
LARGO MD
20774-2122
US

IV. Provider business mailing address

8220 CRESTWOOD HEIGHTS DR APT 607
MC LEAN VA
22102-3129
US

V. Phone/Fax

Practice location:
  • Phone: 703-855-1036
  • Fax: 703-255-5378
Mailing address:
  • Phone: 703-855-1036
  • Fax: 703-255-5378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0051520
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101052350
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD21812
License Number StateDC
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberD0051520
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: