Provider Demographics
NPI:1013904606
Name:MOTAMEDI, ATA (MD)
Entity Type:Individual
Prefix:DR
First Name:ATA
Middle Name:
Last Name:MOTAMEDI
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:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20830-0309
Mailing Address - Country:US
Mailing Address - Phone:301-924-2790
Mailing Address - Fax:301-924-1631
Practice Address - Street 1:17904 GEORGIA AVE
Practice Address - Street 2:SUITE # 304
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-2239
Practice Address - Country:US
Practice Address - Phone:301-924-2790
Practice Address - Fax:301-924-1631
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0063999207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP00307411OtherRR MEDICARE
MD132355OtherJHHC
MD1194549OtherAETNA HMO
MD65112701OtherCAREFIRST BCBS
MD409839100Medicaid
DC0033OtherCAREFIRST BCBS
MD5901543OtherAETNA PPO
DC0033OtherCAREFIRST BCBS
MD409839100Medicaid
MDG02539M01Medicare PIN