Provider Demographics
NPI:1306924741
Name:MOMENI, MAHNAZ (MD)
Entity type:Individual
Prefix:
First Name:MAHNAZ
Middle Name:
Last Name:MOMENI
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 1:8130 BOONE BLVD
Mailing Address - Street 2:SUITE#340
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2666
Mailing Address - Country:US
Mailing Address - Phone:703-734-2222
Mailing Address - Fax:703-734-2223
Practice Address - Street 1:8130 BOONE BLVD
Practice Address - Street 2:SUITE#340
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-2666
Practice Address - Country:US
Practice Address - Phone:703-734-2222
Practice Address - Fax:703-734-2223
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101233154207RR0500X
DCMD34039207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC036856100Medicaid
VA471973886OtherTAX ID NUMBER
VA471973886OtherTAX ID NUMBER
DC036856100Medicaid