Healthcare Provider Details

I. General information

NPI: 1487332904
Provider Name (Legal Business Name): PAYAAM PATRICK TAVAKOLI DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2023
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13460 TREDEGAR LAKE PKWY
MIDLOTHIAN VA
23112-4070
US

IV. Provider business mailing address

13460 TREDEGAR LAKE PKWY
MIDLOTHIAN VA
23112-4070
US

V. Phone/Fax

Practice location:
  • Phone: 804-288-1953
  • Fax:
Mailing address:
  • Phone: 804-288-1953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0103301492
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: