Healthcare Provider Details

I. General information

NPI: 1760169841
Provider Name (Legal Business Name): ALI ISTARABADI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2023
Last Update Date: 06/21/2025
Certification Date: 06/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8310 OLD COURTHOUSE RD
TYSONS VA
22182-3872
US

IV. Provider business mailing address

622 W 168TH ST
NEW YORK NY
10032-3720
US

V. Phone/Fax

Practice location:
  • Phone: 571-773-6582
  • Fax:
Mailing address:
  • Phone: 434-446-7292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number04014119330
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: