Provider Demographics
NPI:1407124506
Name:AHMAD O NOORI MD PC
Entity Type:Organization
Organization Name:AHMAD O NOORI MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING/OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KEISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-742-0061
Mailing Address - Street 1:1860 TOWN CENTER DR
Mailing Address - Street 2:SUITE 280
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-5896
Mailing Address - Country:US
Mailing Address - Phone:703-742-8500
Mailing Address - Fax:703-742-9385
Practice Address - Street 1:1860 TOWN CENTER DR
Practice Address - Street 2:SUITE 280
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5896
Practice Address - Country:US
Practice Address - Phone:703-742-8500
Practice Address - Fax:703-742-9385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101050528174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005826187Medicaid
VA336704OtherANTHEM
VA628390Medicare PIN
VAF17513Medicare UPIN