Provider Demographics
NPI:1952502304
Name:MEHDI BAJOGHLI, M.D., P.C.
Entity Type:Organization
Organization Name:MEHDI BAJOGHLI, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MEHDI
Authorized Official - Middle Name:
Authorized Official - Last Name:BAJOGHLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-490-5803
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101036370174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09373Medicare ID - Type UnspecifiedTRAILBLAZERS