Provider Demographics
NPI:1437689478
Name:TAVAKOLI DASTJERDI, MEHDI (MD)
Entity Type:Individual
Prefix:DR
First Name:MEHDI
Middle Name:
Last Name:TAVAKOLI DASTJERDI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 830941
Mailing Address - Street 2:MSC# 559
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35283
Mailing Address - Country:US
Mailing Address - Phone:205-325-8536
Mailing Address - Fax:205-325-8270
Practice Address - Street 1:2150 PENNSYLVANIA AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20037-3201
Practice Address - Country:US
Practice Address - Phone:202-741-2800
Practice Address - Fax:202-741-2805
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHSE24976207W00000X
ALL.5059SP207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology