1003923665 NPI number — MASSOUM MOAYERY MD

Table of content: MASSOUM MOAYERY MD (NPI 1003923665)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003923665 NPI number — MASSOUM MOAYERY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOAYERY
Provider First Name:
MASSOUM
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003923665
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/14/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 INDEPENDENCE CIRCLE
Provider Second Line Business Mailing Address:
SUITE 2D
Provider Business Mailing Address City Name:
VIRGINIA BEACH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23455
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-497-1987
Provider Business Mailing Address Fax Number:
757-671-7002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 INDEPENDENCE CIRCLE
Provider Second Line Business Practice Location Address:
SUITE 2D
Provider Business Practice Location Address City Name:
VIRGINIA BEACH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-497-1987
Provider Business Practice Location Address Fax Number:
757-671-7002
Provider Enumeration Date:
08/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  0101034804 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4041932 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1386878 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 321182 . This is a "MAMSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6304281 . This is a "VIRGINIA PREMIER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 35052 . This is a "SENTARA/OPTIMA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 006304281 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08-00045 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 330961 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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