Provider Demographics
NPI:1558619254
Name:LAKE RIDGE ANESTHESIA LLC
Entity Type:Organization
Organization Name:LAKE RIDGE ANESTHESIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REZA
Authorized Official - Middle Name:
Authorized Official - Last Name:IZADI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:301-829-7683
Mailing Address - Street 1:1302 RISING RIDGE RD
Mailing Address - Street 2:# 1
Mailing Address - City:MOUNT AIRY
Mailing Address - State:MD
Mailing Address - Zip Code:21771-5790
Mailing Address - Country:US
Mailing Address - Phone:301-829-7683
Mailing Address - Fax:301-829-7694
Practice Address - Street 1:12825 MINNIEVILLE ROAD
Practice Address - Street 2:# 220
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192
Practice Address - Country:US
Practice Address - Phone:301-829-7386
Practice Address - Fax:301-829-7694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-28
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101237760207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty