Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QG0300X | Family Doctor - Geriatric Medicine | 0101241072 | VA |
N | 207QG0300X | Family Doctor - Geriatric Medicine | 22758 | WV |
NPI | 1013136464 |
---|---|
Provider Name | Dr. Mehran Khajavi |
First Address | Leesburg, VA 20177 |
Second Address | Martinsburg, WV 25401-8801 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/04/2007 |
Last Update Date | 08/06/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
P00449865 | RAILROAD MEDICARE (01) | WV |
WV2358C487 | MEDICARE PTAN (01) | WV |