Provider Demographics
NPI:1578510715
Name:YAZDANI, KAMBIZ (MD)
Entity Type:Individual
Prefix:DR
First Name:KAMBIZ
Middle Name:
Last Name:YAZDANI
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:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22194-0037
Mailing Address - Country:US
Mailing Address - Phone:703-492-0709
Mailing Address - Fax:703-492-7323
Practice Address - Street 1:14904 JEFFERSON DAVIS HWY
Practice Address - Street 2:#106
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3908
Practice Address - Country:US
Practice Address - Phone:703-492-6822
Practice Address - Fax:703-492-6826
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101237219174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAI26987Medicare UPIN