Healthcare Provider Details

I. General information

NPI: 1437326816
Provider Name (Legal Business Name): ENDOSCOPY & DIGESTIVE CENTER OF WOODBRIDGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14904 JEFFERSON DAVIS HWY SUITE 103 & 104
WOODBRIDGE VA
22191-3908
US

IV. Provider business mailing address

14904 JEFFERSON DAVIS HWY SUITE 104
WOODBRIDGE VA
22191-3908
US

V. Phone/Fax

Practice location:
  • Phone: 703-497-4222
  • Fax: 703-492-0164
Mailing address:
  • Phone: 703-497-4222
  • Fax: 703-492-0164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number0101049080
License Number StateVA

VIII. Authorized Official

Name: DR. MOHAMMAD HOSSEIN RAZAVI
Title or Position: OWNER
Credential: MD
Phone: 703-497-4222