Provider Demographics
NPI:1063734820
Name:MORTEZA S. MOUSAVI, M.D., P.C.
Entity type:Organization
Organization Name:MORTEZA S. MOUSAVI, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MORTEZA
Authorized Official - Middle Name:S
Authorized Official - Last Name:MOUSAVI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-878-0941
Mailing Address - Street 1:2296 OPITZ BLVD.
Mailing Address - Street 2:SUITE 340
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3346
Mailing Address - Country:US
Mailing Address - Phone:703-878-0941
Mailing Address - Fax:703-878-0857
Practice Address - Street 1:2296 OPITZ BLVD
Practice Address - Street 2:SUITE 340
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3300
Practice Address - Country:US
Practice Address - Phone:703-878-0941
Practice Address - Fax:703-878-0857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-22
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101033951174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006033989Medicaid
VAC11012Medicare PIN
VA006033989Medicaid