MEDICARE: MRS. FARZANA MOHTASHAM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	0101058524	VA

General Provider Information

NPI Number	:	1225146947
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. FARZANA MOHTASHAM MD

Provider Business Mailing Address
First Line	:	6330 N CENTER DR
Second Line	:	BLDG 13 SUITE 220
City	:	NORFOLK
State	:	VA
Zip	:	23502-4008
Country	:	US
Telephone Number	:	757-466-0089
Fax Number	:	757-466-8017

Provider Business Practice Location Address
First Line	:	6330 N CENTER DR
Second Line	:	BLDG 13 SUITE 220
City	:	NORFOLK
State	:	VA
Zip	:	23502-4008
Country	:	US
Telephone Number	:	757-466-0089
Fax Number	:	757-466-8017

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2006
Last Update Date	:	07/08/2007

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