Provider Demographics
NPI:1407860794
Name:MOGHISSI, JASMINE WANDA (MD)
Entity Type:Individual
Prefix:DR
First Name:JASMINE
Middle Name:WANDA
Last Name:MOGHISSI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:9401 LEE HWY
Mailing Address - Street 2:SUITE 302
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-1849
Mailing Address - Country:US
Mailing Address - Phone:703-281-5560
Mailing Address - Fax:703-281-5568
Practice Address - Street 1:9401 LEE HWY
Practice Address - Street 2:SUITE 302
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-1849
Practice Address - Country:US
Practice Address - Phone:703-281-5560
Practice Address - Fax:703-281-5568
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-29
Last Update Date:2009-08-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0101044043207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAE40807Medicare UPIN
DCG00873Medicare PIN