Provider Demographics
NPI:1134207525
Name:BAHADORI, MOHAMMAD (MD)
Entity type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:BAHADORI
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 1:14904 JEFFERSON DAVIS HWY
Mailing Address - Street 2:SUITE 203
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3908
Mailing Address - Country:US
Mailing Address - Phone:703-492-6660
Mailing Address - Fax:703-492-6661
Practice Address - Street 1:14904 JEFFERSON DAVIS HWY
Practice Address - Street 2:SUITE 203
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3908
Practice Address - Country:US
Practice Address - Phone:703-492-6660
Practice Address - Fax:703-492-6661
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101053161207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAB77436Medicare UPIN