Provider Demographics
NPI:1437326816
Name:ENDOSCOPY & DIGESTIVE CENTER OF WOODBRIDGE
Entity Type:Organization
Organization Name:ENDOSCOPY & DIGESTIVE CENTER OF WOODBRIDGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:HOSSEIN
Authorized Official - Last Name:RAZAVI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-497-4222
Mailing Address - Street 1:14904 JEFFERSON DAVIS HWY
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3908
Mailing Address - Country:US
Mailing Address - Phone:703-497-4222
Mailing Address - Fax:703-492-0164
Practice Address - Street 1:14904 JEFFERSON DAVIS HWY
Practice Address - Street 2:SUITE 103 & 104
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3908
Practice Address - Country:US
Practice Address - Phone:703-497-4222
Practice Address - Fax:703-492-0164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101049080261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006077871Medicaid
VA006077871Medicaid