Provider Demographics
NPI:1689765760
Name:TAJAMMUL EHSAN MD PC
Entity Type:Organization
Organization Name:TAJAMMUL EHSAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TAJAMMUL
Authorized Official - Middle Name:
Authorized Official - Last Name:EHSAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-787-7638
Mailing Address - Street 1:722 GRANT ST
Mailing Address - Street 2:STE. F
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4532
Mailing Address - Country:US
Mailing Address - Phone:703-787-7638
Mailing Address - Fax:703-787-7654
Practice Address - Street 1:722 GRANT ST
Practice Address - Street 2:STE. F
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4532
Practice Address - Country:US
Practice Address - Phone:703-787-7638
Practice Address - Fax:703-787-7654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012323882084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC08522Medicare PIN
VAG00973Medicare PIN