Healthcare Provider Details

I. General information

NPI: 1932156056
Provider Name (Legal Business Name): MASOUD S HEJAZI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 09/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 PINEY FOREST RD
DANVILLE VA
24540-2860
US

IV. Provider business mailing address

705 PINEY FOREST RD
DANVILLE VA
24540-2860
US

V. Phone/Fax

Practice location:
  • Phone: 434-710-4210
  • Fax: 434-792-1471
Mailing address:
  • Phone: 434-710-4210
  • Fax: 434-792-1471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number0101053286
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number33063
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: