=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235755851
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EHSAN JAFREE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2020
-----------------------------------------------------
Last Update Date | 01/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1401 JOHNSTON WILLIS DR
-----------------------------------------------------
City | NORTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23235-4730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-483-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 980257
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23298-0257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-828-9783
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 0101278815
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------