Provider Demographics
NPI:1669733754
Name:TAZAMAL, MEMONA (MD)
Entity type:Individual
Prefix:DR
First Name:MEMONA
Middle Name:
Last Name:TAZAMAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11901 GEORGIA AVE
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:MD
Mailing Address - Zip Code:20902-2001
Mailing Address - Country:US
Mailing Address - Phone:301-325-3504
Mailing Address - Fax:
Practice Address - Street 1:11901 GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:MD
Practice Address - Zip Code:20902-2001
Practice Address - Country:US
Practice Address - Phone:301-325-3504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-05
Last Update Date:2023-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116024334390200000X
MDD82355207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
207OOOOOXOtherFAMILY MEDICINE
VA207QOOOOOXOtherFAMILY MEDICINE