Provider Demographics
NPI:1760583397
Name:EHSAN, TAJAMMUL (MD)
Entity Type:Individual
Prefix:
First Name:TAJAMMUL
Middle Name:
Last Name:EHSAN
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 1:722 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
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012323882084N0400X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7117787Medicaid
VAG28905Medicare UPIN
VA7117787Medicaid
VA00B339T73Medicare PIN