Healthcare Provider Details

I. General information

NPI: 1942740352
Provider Name (Legal Business Name): SAMIRA HANNAH REZAIAN D.O
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2017
Last Update Date: 11/25/2022
Certification Date: 11/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8081 INNOVATION PARK DR STE 200
FAIRFAX VA
22031-4867
US

IV. Provider business mailing address

8081 INNOVATION PARK DR STE 500
FAIRFAX VA
22031-4867
US

V. Phone/Fax

Practice location:
  • Phone: 571-472-7000
  • Fax: 571-472-7001
Mailing address:
  • Phone: 571-472-7000
  • Fax: 571-472-7001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS17616
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number0102207204
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: