Provider Demographics
NPI:1336658939
Name:DOROST, MISAGH MICHAEL
Entity Type:Individual
Prefix:
First Name:MISAGH
Middle Name:MICHAEL
Last Name:DOROST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21226 VIRGINIA PINE TER
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20876-4382
Mailing Address - Country:US
Mailing Address - Phone:240-388-5240
Mailing Address - Fax:
Practice Address - Street 1:301 RUSSELL AVE
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-2807
Practice Address - Country:US
Practice Address - Phone:301-216-4248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-26
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD08107225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist