Provider Demographics
NPI:1639167661
Name:RAZAVI, MOHAMMAD HOSSEIN (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:HOSSEIN
Last Name:RAZAVI
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 1:14904 JEFFERSON DAVIS HWY
Mailing Address - Street 2:SUITE #103
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3908
Mailing Address - Country:US
Mailing Address - Phone:703-497-4222
Mailing Address - Fax:703-492-0164
Practice Address - Street 1:14904 JEFFERSON DAVIS HWY
Practice Address - Street 2:SUITE #103
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3908
Practice Address - Country:US
Practice Address - Phone:703-497-4222
Practice Address - Fax:703-492-0164
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101049080207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006077871Medicaid
VARA068221Medicare ID - Type Unspecified
VA006077871Medicaid
VA100000286Medicare PIN