Provider Demographics
NPI:1720346026
Name:KORDESTANI, REZA (MD)
Entity Type:Individual
Prefix:DR
First Name:REZA
Middle Name:
Last Name:KORDESTANI
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 1:4660 KENMORE AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-1306
Mailing Address - Country:US
Mailing Address - Phone:703-832-4000
Mailing Address - Fax:703-832-4001
Practice Address - Street 1:4660 KENMORE AVE STE 220
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1306
Practice Address - Country:US
Practice Address - Phone:703-832-4000
Practice Address - Fax:703-832-4001
Is Sole Proprietor?:No
Enumeration Date:2012-04-25
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD0460082086S0122X
MDD0085597208200000X
VA0101263685208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery