Provider Demographics
NPI:1972117372
Name:SHAHMIRZADI, MARTIN A
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:A
Last Name:SHAHMIRZADI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1934 OLD GALLOWS RD STE 350B
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-4042
Mailing Address - Country:US
Mailing Address - Phone:703-568-5076
Mailing Address - Fax:
Practice Address - Street 1:1934 OLD GALLOWS RD STE 350B
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-4042
Practice Address - Country:US
Practice Address - Phone:703-568-5076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1101003537156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician