Provider Demographics
NPI:1386719524
Name:HISPANIC AMERICAN PEDIATRIC ASSOCIATES
Entity type:Organization
Organization Name:HISPANIC AMERICAN PEDIATRIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEMAL
Authorized Official - Middle Name:
Authorized Official - Last Name:OMIDVAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-751-2021
Mailing Address - Street 1:5130 DUKE ST STE 7
Mailing Address - Street 2:SUITE 229
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-2955
Mailing Address - Country:US
Mailing Address - Phone:703-751-2021
Mailing Address - Fax:703-751-2071
Practice Address - Street 1:5130 DUKE STREET
Practice Address - Street 2:SUITE 7
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-7207
Practice Address - Country:US
Practice Address - Phone:703-751-2021
Practice Address - Fax:703-751-2071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA40990-01261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010117534Medicaid
MD002632800Medicaid
VA010125561Medicaid