Provider Demographics
NPI:1235543224
Name:KHAJAVI, MARISSA LEIGH (MD)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:LEIGH
Last Name:KHAJAVI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1111 N CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-5505
Mailing Address - Country:US
Mailing Address - Phone:410-837-2050
Mailing Address - Fax:866-629-0091
Practice Address - Street 1:5500 KNOLL NORTH DR STE 370
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2393
Practice Address - Country:US
Practice Address - Phone:410-837-2050
Practice Address - Fax:866-629-0091
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDP30079207V00000X
MDD00852292083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Single Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty