Healthcare Provider Details

I. General information

NPI: 1508252784
Provider Name (Legal Business Name): MOHAMMAD-ALI YAZDANI ABYANEH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2015
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2296 OPITZ BLVD STE 250
WOODBRIDGE VA
22191-3345
US

IV. Provider business mailing address

1729 BURRSTONE RD
NEW HARTFORD NY
13413-1001
US

V. Phone/Fax

Practice location:
  • Phone: 703-844-4267
  • Fax: 703-982-7238
Mailing address:
  • Phone: 315-798-1832
  • Fax: 315-798-1432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number299230
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number0101286129
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: