Provider Demographics
NPI:1396942603
Name:HABIBPOUR, EHSAN (MD)
Entity type:Individual
Prefix:
First Name:EHSAN
Middle Name:
Last Name:HABIBPOUR
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 1:6862 ELM ST STE 205
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3857
Mailing Address - Country:US
Mailing Address - Phone:703-821-1073
Mailing Address - Fax:703-288-0767
Practice Address - Street 1:6862 ELM ST STE 205
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101
Practice Address - Country:US
Practice Address - Phone:703-821-1073
Practice Address - Fax:703-288-0767
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012505612084P0804X, 2084P0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty