Provider Demographics
NPI:1306812870
Name:MORTAZAVI, ALA SAYED (MD)
Entity Type:Individual
Prefix:DR
First Name:ALA
Middle Name:SAYED
Last Name:MORTAZAVI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:313 PARK AVE SUITE 202
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-3327
Mailing Address - Country:US
Mailing Address - Phone:703-497-0212
Mailing Address - Fax:703-497-0421
Practice Address - Street 1:2028 OPITZ BLVD.
Practice Address - Street 2:SUITE B
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191
Practice Address - Country:US
Practice Address - Phone:703-497-0212
Practice Address - Fax:703-497-0421
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101047023207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005813166Medicaid
VA290012157OtherRAIL ROAD MEDICARE
VA290011028OtherRAIL ROAD MEDICARE
VAE57205Medicare UPIN
VA005813166Medicaid
VA290000219Medicare PIN