1437689478 NPI number — DR. MEHDI TAVAKOLI DASTJERDI MD

Table of content: DR. MEHDI TAVAKOLI DASTJERDI MD (NPI 1437689478)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437689478 NPI number — DR. MEHDI TAVAKOLI DASTJERDI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAVAKOLI DASTJERDI
Provider First Name:
MEHDI
Provider Middle Name:
Provider Name Prefix Text:
DR.
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:
1437689478
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 830941
Provider Second Line Business Mailing Address:
MSC# 559
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35283
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-325-8536
Provider Business Mailing Address Fax Number:
205-325-8270

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2150 PENNSYLVANIA AVE NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
DC
Provider Business Practice Location Address Postal Code:
20037-3201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-741-2800
Provider Business Practice Location Address Fax Number:
202-741-2805
Provider Enumeration Date:
06/13/2017

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:  HSE24976 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: L.5059SP , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100842600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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