Provider Demographics
NPI:1073744025
Name:ROSTAMI, MARYAM (MD)
Entity Type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:
Last Name:ROSTAMI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13609 CARROLLTON BLVD
Mailing Address - Street 2:SUITE 11
Mailing Address - City:CARROLLTON
Mailing Address - State:VA
Mailing Address - Zip Code:23314-3214
Mailing Address - Country:US
Mailing Address - Phone:757-238-8751
Mailing Address - Fax:757-238-8750
Practice Address - Street 1:13609 CARROLLTON BLVD
Practice Address - Street 2:SUITE 11
Practice Address - City:CARROLLTON
Practice Address - State:VA
Practice Address - Zip Code:23314-3214
Practice Address - Country:US
Practice Address - Phone:757-238-8751
Practice Address - Fax:757-238-8750
Is Sole Proprietor?:No
Enumeration Date:2009-08-06
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101246234207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA021062M03Medicare PIN
VA022332M55Medicare PIN