Provider Demographics
NPI:1427445634
Name:KHOSHNEVISAN, MOHAMMAD ALI (MD, MBA)
Entity type:Individual
Prefix:DR
First Name:MOHAMMAD ALI
Middle Name:
Last Name:KHOSHNEVISAN
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 TOWN CENTER DR STE 300
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-5900
Mailing Address - Country:US
Mailing Address - Phone:703-435-6604
Mailing Address - Fax:703-662-4506
Practice Address - Street 1:1860 TOWN CENTER DR STE 300
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5900
Practice Address - Country:US
Practice Address - Phone:703-435-6605
Practice Address - Fax:703-662-4506
Is Sole Proprietor?:No
Enumeration Date:2015-04-26
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101272648207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program