Provider Demographics
NPI:1588144588
Name:ETESAM, AMIR
Entity type:Individual
Prefix:
First Name:AMIR
Middle Name:
Last Name:ETESAM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 EXECUTIVE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:NORTH BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20852-3816
Mailing Address - Country:US
Mailing Address - Phone:240-599-1001
Mailing Address - Fax:
Practice Address - Street 1:6000 EXECUTIVE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:NORTH BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20852-3816
Practice Address - Country:US
Practice Address - Phone:240-599-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-19
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00909232084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program