Provider Demographics
NPI:1568758951
Name:JAZINI, EHSAN (MD)
Entity Type:Individual
Prefix:
First Name:EHSAN
Middle Name:
Last Name:JAZINI
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 1:11800 SUNRISE VALLEY DR STE 600
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-5327
Mailing Address - Country:US
Mailing Address - Phone:703-709-1114
Mailing Address - Fax:703-709-1117
Practice Address - Street 1:11800 SUNRISE VALLEY DR STE 600
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191
Practice Address - Country:US
Practice Address - Phone:703-709-1114
Practice Address - Fax:703-709-1117
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY49233207X00000X
VA0101262789207X00000X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100422590Medicaid
KY201379230Medicaid
MD870300100Medicaid
DC017293178Medicaid