Provider Demographics
NPI:1760072276
Name:ROOZBEH, DIBA
Entity Type:Individual
Prefix:
First Name:DIBA
Middle Name:
Last Name:ROOZBEH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 AMBERFIELD LN
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-2770
Mailing Address - Country:US
Mailing Address - Phone:240-506-1692
Mailing Address - Fax:
Practice Address - Street 1:50 W EDMONSTON DR
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-1228
Practice Address - Country:US
Practice Address - Phone:240-403-0152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD30145120183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician