Healthcare Provider Details

I. General information

NPI: 1982673364
Provider Name (Legal Business Name): NIV AD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 03/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 MAPLE AVE SUITE A
TAKOMA PARK MD
20912-6331
US

IV. Provider business mailing address

7901 MAPLE AVE STE A SUITE 140
TAKOMA PARK MD
20912-6331
US

V. Phone/Fax

Practice location:
  • Phone: 202-524-4200
  • Fax:
Mailing address:
  • Phone: 202-524-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101246383
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number0101246383
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0101246383
License Number StateVA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier010111510
Identifier TypeMEDICAID
Identifier StateVA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: