Provider Demographics
NPI:1225072077
Name:HEYDARIAN, SIAMAK (MD)
Entity Type:Individual
Prefix:DR
First Name:SIAMAK
Middle Name:
Last Name:HEYDARIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 OPITZ BLVD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3321
Mailing Address - Country:US
Mailing Address - Phone:703-497-6700
Mailing Address - Fax:703-497-6300
Practice Address - Street 1:2200 OPITZ BLVD
Practice Address - Street 2:SUITE 350
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3321
Practice Address - Country:US
Practice Address - Phone:703-497-6700
Practice Address - Fax:703-497-6300
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101048248207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
110228399OtherRR MEDICARE
1452619015OtherCIGNA
VA433755OtherANTHEM BCBS
61910001OtherCAREFIRST BC BS
194200OtherAMERIGROUP
289363OtherMAMSI
150789200OtherDEPT OF LABOR
VA5853451Medicaid
102386OtherAETNA
110007840Medicare PIN
150789200OtherDEPT OF LABOR