Provider Demographics
NPI:1699868786
Name:BAJOGHLI, MEHRAN (MD)
Entity type:Individual
Prefix:
First Name:MEHRAN
Middle Name:
Last Name:BAJOGHLI
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 1:1570 ONYX DR UNIT 305
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-3957
Mailing Address - Country:US
Mailing Address - Phone:703-244-9117
Mailing Address - Fax:571-200-2618
Practice Address - Street 1:1570 ONYX DR UNIT 305
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-3957
Practice Address - Country:US
Practice Address - Phone:703-244-9117
Practice Address - Fax:571-200-2618
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA07395207U00000X
VA0101231597207RA0401X, 208D00000X, 208D00000X, 2083A0300X
DCMD0358882085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30016041500017Medicaid
6B8333OtherMEDICARE