Provider Demographics
NPI:1629073994
Name:GOUDARZI, BEHNAM M (MD)
Entity Type:Individual
Prefix:
First Name:BEHNAM
Middle Name:M
Last Name:GOUDARZI
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 1:2028 OPITZ BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3326
Mailing Address - Country:US
Mailing Address - Phone:703-497-0212
Mailing Address - Fax:703-497-0421
Practice Address - Street 1:2028 OPITZ BLVD STE B
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3326
Practice Address - Country:US
Practice Address - Phone:703-497-0212
Practice Address - Fax:703-497-0421
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101239238207RS0012X, 207RP1001X
VA0101238239207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010277710Medicaid
VA018496V10Medicare PIN
VAH82007Medicare UPIN
VA010277710Medicaid