Provider Demographics
NPI:1104835354
Name:TAMJIDI, PANTEHA (MD)
Entity type:Individual
Prefix:DR
First Name:PANTEHA
Middle Name:
Last Name:TAMJIDI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211A TOWLSTON RD
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:VA
Mailing Address - Zip Code:22066-2216
Mailing Address - Country:US
Mailing Address - Phone:703-759-1121
Mailing Address - Fax:703-356-0447
Practice Address - Street 1:5454 WISCONSIN AVE
Practice Address - Street 2:SUITE 1045
Practice Address - City:CHEVY CHASE
Practice Address - State:MD
Practice Address - Zip Code:20815-6917
Practice Address - Country:US
Practice Address - Phone:301-652-4828
Practice Address - Fax:301-652-2070
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101231459207N00000X
MDD0063624207N00000X, 207NS0135X
DCMD0354490207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCP00350841Medicare PIN
DCG02266T01Medicare PIN
MDI50152Medicare UPIN