Healthcare Provider Details

I. General information

NPI: 1619453966
Provider Name (Legal Business Name): M & M PATHOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2018
Last Update Date: 07/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2280 OPITZ BLVD STE 200
WOODBRIDGE VA
22191-3330
US

IV. Provider business mailing address

2280 OPITZ BLVD STE 200
WOODBRIDGE VA
22191-3330
US

V. Phone/Fax

Practice location:
  • Phone: 703-580-7433
  • Fax: 703-580-7437
Mailing address:
  • Phone: 703-580-7433
  • Fax: 703-580-7437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: KIAN MAKIPOUR
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 703-580-7433