Provider Demographics
NPI:1285612887
Name:MARDINI, MOHAMED (MD)
Entity type:Individual
Prefix:
First Name:MOHAMED
Middle Name:
Last Name:MARDINI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8100 ASHTON AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-5688
Mailing Address - Country:US
Mailing Address - Phone:703-331-0300
Mailing Address - Fax:703-331-0254
Practice Address - Street 1:8100 ASHTON AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-5688
Practice Address - Country:US
Practice Address - Phone:703-335-8750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010236332080P0202X
MDD00158982080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D09657Medicare UPIN