Provider Demographics
NPI:1770663882
Name:POOYA, MANOOCHEHR (MD)
Entity Type:Individual
Prefix:DR
First Name:MANOOCHEHR
Middle Name:
Last Name:POOYA
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 1:11021 BALANTRE LANE
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-1323
Mailing Address - Country:US
Mailing Address - Phone:202-543-8067
Mailing Address - Fax:301-983-4036
Practice Address - Street 1:700 7TH ST SW
Practice Address - Street 2:G2
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20024-2442
Practice Address - Country:US
Practice Address - Phone:202-543-8067
Practice Address - Fax:301-983-4036
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC4594207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
142901Medicare UPIN
C62031Medicare ID - Type Unspecified