Provider Demographics
NPI:1083974307
Name:SHADY GROVE MINIMALLY INVASIVE
Entity Type:Organization
Organization Name:SHADY GROVE MINIMALLY INVASIVE
Other - Org Name:SHABNAM DADGAR
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHABNAM
Authorized Official - Middle Name:
Authorized Official - Last Name:DADGAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-868-1235
Mailing Address - Street 1:11 WELWYN WAY
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-2744
Mailing Address - Country:US
Mailing Address - Phone:703-868-1235
Mailing Address - Fax:
Practice Address - Street 1:2403 RESEARCH BLVD
Practice Address - Street 2:STE 200
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-6233
Practice Address - Country:US
Practice Address - Phone:703-868-1235
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-21
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0072779174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty