Provider Demographics
NPI:1609373638
Name:MANOOCHEHRI, OMID
Entity Type:Individual
Prefix:
First Name:OMID
Middle Name:
Last Name:MANOOCHEHRI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1468 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6508
Mailing Address - Country:US
Mailing Address - Phone:212-824-8069
Mailing Address - Fax:
Practice Address - Street 1:4320 SEMINARY RD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1535
Practice Address - Country:US
Practice Address - Phone:240-686-2300
Practice Address - Fax:240-686-2330
Is Sole Proprietor?:No
Enumeration Date:2018-04-06
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101274870207P00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine