Healthcare Provider Details

I. General information

NPI: 1497440234
Provider Name (Legal Business Name): EHSAUN HEYDARI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2023
Last Update Date: 06/07/2025
Certification Date: 06/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 N 11TH ST
RICHMOND VA
23298-5024
US

IV. Provider business mailing address

VCUHS GME ADMINISTRATION BOX 980257
RICHMOND VA
23298-0257
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-9165
  • Fax: 804-828-4493
Mailing address:
  • Phone: 804-828-9783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number1497440234
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: