Healthcare Provider Details

I. General information

NPI: 1568405215
Provider Name (Legal Business Name): MAHTAB VAZIRI OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 02/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15200 SHADY GROVE RD SUITE 100
ROCKVILLE MD
20850-3218
US

IV. Provider business mailing address

7825 TUCKAHOE CT
FULTON MD
20759-2599
US

V. Phone/Fax

Practice location:
  • Phone: 301-670-1212
  • Fax: 301-216-9692
Mailing address:
  • Phone: 703-618-1933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618001518
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: