Healthcare Provider Details

I. General information

NPI: 1699868786
Provider Name (Legal Business Name): MEHRAN BAJOGHLI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 05/24/2024
Certification Date: 05/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1570 ONYX DR UNIT 305
MC LEAN VA
22102-3957
US

IV. Provider business mailing address

1570 ONYX DR UNIT 305
MC LEAN VA
22102-3957
US

V. Phone/Fax

Practice location:
  • Phone: 703-244-9117
  • Fax: 571-200-2618
Mailing address:
  • Phone: 703-244-9117
  • Fax: 571-200-2618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number07395
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number0101231597
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101231597
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: