Provider Demographics
NPI:1356435515
Name:TAVALLALI, MORAD (MD)
Entity type:Individual
Prefix:MR
First Name:MORAD
Middle Name:
Last Name:TAVALLALI
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 1:8245 BOONE BLVD
Mailing Address - Street 2:SUITE 540
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3828
Mailing Address - Country:US
Mailing Address - Phone:703-876-9400
Mailing Address - Fax:
Practice Address - Street 1:8245 BOONE BLVD
Practice Address - Street 2:SUITE 540
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-3828
Practice Address - Country:US
Practice Address - Phone:703-876-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101049018174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist