Provider Demographics
NPI:1356756795
Name:AMIRJAZIL, IDEAN
Entity type:Individual
Prefix:
First Name:IDEAN
Middle Name:
Last Name:AMIRJAZIL
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 1:220 CAMPUS BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-2896
Mailing Address - Country:US
Mailing Address - Phone:540-536-5100
Mailing Address - Fax:540-536-0235
Practice Address - Street 1:1880 AMHERST STREET
Practice Address - Street 2:SUITE 100 AND SUITE 200
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-6254
Practice Address - Country:US
Practice Address - Phone:540-662-0306
Practice Address - Fax:855-264-2066
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-24
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV29563207RC0000X
PAMT207582282N00000X
VA0101268593207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No282N00000XHospitalsGeneral Acute Care Hospital