Provider Demographics
NPI:1407059413
Name:TAVAKOLI-JALILI, NADER (MD)
Entity Type:Individual
Prefix:DR
First Name:NADER
Middle Name:
Last Name:TAVAKOLI-JALILI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:NADER
Other - Middle Name:
Other - Last Name:TAVAKOLI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:626C ADMIRAL DR
Mailing Address - Street 2:# 235
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-2151
Mailing Address - Country:US
Mailing Address - Phone:301-352-7118
Mailing Address - Fax:
Practice Address - Street 1:9500 MEDICAL CENTER DR # 3230-F
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-3701
Practice Address - Country:US
Practice Address - Phone:301-352-7118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0041978207QA0505X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD305791700Medicaid
MDB181OtherBCBS PROV #
MD305791700Medicaid
MD199M254FMedicare PIN