Healthcare Provider Details

I. General information

NPI: 1609845429
Provider Name (Legal Business Name): AZADEH KOOCHEKZADEH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 04/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4660 KENMORE AVE STE 500
ALEXANDRIA VA
22304
US

IV. Provider business mailing address

1707 OSAGE ST STE 104
ALEXANDRIA VA
22302
US

V. Phone/Fax

Practice location:
  • Phone: 703-212-6600
  • Fax: 703-212-6606
Mailing address:
  • Phone: 703-212-6600
  • Fax: 703-931-0961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number101230323
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: