Provider Demographics
NPI:1265502389
Name:PISHDAD, BAHRAM (MD)
Entity Type:Individual
Prefix:DR
First Name:BAHRAM
Middle Name:
Last Name:PISHDAD
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 1:8220 CRESTWOOD HEIGHTS DR
Mailing Address - Street 2:APT 607
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-3129
Mailing Address - Country:US
Mailing Address - Phone:703-855-1036
Mailing Address - Fax:703-255-5378
Practice Address - Street 1:600 LARGO RD
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-2122
Practice Address - Country:US
Practice Address - Phone:703-855-1036
Practice Address - Fax:703-255-5378
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101052350208D00000X
MDD0051520207R00000X, 208D00000X
DCMD21812208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD795007100Medicaid
DC017251600Medicaid
DC017251600Medicaid
MD795007100Medicaid