Provider Demographics
NPI:1811925928
Name:GHAFOURI, MERDOD (DO)
Entity type:Individual
Prefix:
First Name:MERDOD
Middle Name:
Last Name:GHAFOURI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:MOHAMMAD
Other - Middle Name:R
Other - Last Name:GHAFOURI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:8100 ASHTON AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-5688
Mailing Address - Country:US
Mailing Address - Phone:703-335-8750
Mailing Address - Fax:571-358-3941
Practice Address - Street 1:7617 LITTLE RIVER TURN PIKE
Practice Address - Street 2:SUITE 710
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-2635
Practice Address - Country:US
Practice Address - Phone:703-335-5750
Practice Address - Fax:571-358-3941
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102201022207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC08583OtherPTAN MHC
DC00A989V73OtherMEDICARE DC
VAC09878OtherPTAN WHC
VAC06380OtherMEDICARE VA PTAN
DCG00773OtherMEDICARE DC PTAN
VAC09878OtherPTAN WHC
VAG71229Medicare UPIN