Provider Demographics
NPI:1154378511
Name:MOJALLAL, PEYAM (OD)
Entity type:Individual
Prefix:DR
First Name:PEYAM
Middle Name:
Last Name:MOJALLAL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20600 GORDON PARK SQ
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-3145
Mailing Address - Country:US
Mailing Address - Phone:703-723-3433
Mailing Address - Fax:703-723-1920
Practice Address - Street 1:20600 GORDON PARK SQ
Practice Address - Street 2:SUITE 150
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-3145
Practice Address - Country:US
Practice Address - Phone:703-723-3433
Practice Address - Fax:703-723-1920
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001051152W00000X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9236805Medicaid
U89477Medicare UPIN
DCG01946P01Medicare PIN
VA00W337P01Medicare PIN
VA9236805Medicaid