Provider Demographics
NPI:1770548893
Name:MOGHADAM, FARANAK E (MD)
Entity type:Individual
Prefix:
First Name:FARANAK
Middle Name:E
Last Name:MOGHADAM
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 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:3357B CORRIDOR MARKETPLACE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20724-2381
Practice Address - Country:US
Practice Address - Phone:301-497-1820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101269960207Q00000X
MDD0053640207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD080171343OtherRAILROAD MEDICARE
MD945L481EMedicare PIN
NJ477144ZPCNMedicare PIN
MD150956ZDDBMedicare PIN
MDG82490Medicare UPIN
MD345306YWV2Medicare PIN