Provider Demographics
NPI:1801491386
Name:BASIRI, OMEED AZZAT
Entity type:Individual
Prefix:
First Name:OMEED
Middle Name:AZZAT
Last Name:BASIRI
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 1:640 PEMBERTON DR APT 5
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-6334
Mailing Address - Country:US
Mailing Address - Phone:317-893-6108
Mailing Address - Fax:
Practice Address - Street 1:640 PEMBERTON DR APT 5
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-6334
Practice Address - Country:US
Practice Address - Phone:317-893-6108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305212638225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist