Provider Demographics
NPI:1457490989
Name:FARIVARI, ABRAHAM (MD)
Entity Type:Individual
Prefix:
First Name:ABRAHAM
Middle Name:
Last Name:FARIVARI
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 1:6196 OXON HILL ROAD
Mailing Address - Street 2:#440
Mailing Address - City:OXON HILL
Mailing Address - State:MD
Mailing Address - Zip Code:20745-3127
Mailing Address - Country:US
Mailing Address - Phone:301-839-0334
Mailing Address - Fax:301-749-8788
Practice Address - Street 1:6228 OXON HILL RD
Practice Address - Street 2:
Practice Address - City:OXON HILL
Practice Address - State:MD
Practice Address - Zip Code:20745-3033
Practice Address - Country:US
Practice Address - Phone:301-839-0334
Practice Address - Fax:301-749-8788
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2012-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0020550208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC011605900Medicaid
MD186921300Medicaid
DC011605900Medicaid
MD186921300Medicaid