Healthcare Provider Details

I. General information

NPI: 1225072077
Provider Name (Legal Business Name): SIAMAK HEYDARIAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 01/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 OPITZ BLVD SUITE 350
WOODBRIDGE VA
22191-3321
US

IV. Provider business mailing address

2200 OPITZ BLVD SUITE 350
WOODBRIDGE VA
22191-3321
US

V. Phone/Fax

Practice location:
  • Phone: 703-497-6700
  • Fax: 703-497-6300
Mailing address:
  • Phone: 703-497-6700
  • Fax: 703-497-6300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101048248
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: