Provider Demographics
NPI:1720193048
Name:BAJOGHLI, MEHDI (MD)
Entity Type:Individual
Prefix:DR
First Name:MEHDI
Middle Name:
Last Name:BAJOGHLI
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 1:2200 OPITZ BLVD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3321
Mailing Address - Country:US
Mailing Address - Phone:703-490-5803
Mailing Address - Fax:703-490-6443
Practice Address - Street 1:2200 OPITZ BLVD
Practice Address - Street 2:SUITE 230
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3321
Practice Address - Country:US
Practice Address - Phone:703-490-5803
Practice Address - Fax:703-490-6443
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09373Medicare ID - Type UnspecifiedTRAILBLAZERS
VAB06422Medicare UPIN