Provider Demographics
NPI:1699886861
Name:HAMID R POURSHOJAE DO PC
Entity type:Organization
Organization Name:HAMID R POURSHOJAE DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:HAMID
Authorized Official - Middle Name:R
Authorized Official - Last Name:POURSHOJAE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:703-878-7610
Mailing Address - Street 1:2280 OPITZ BLVD
Mailing Address - Street 2:SUITE 320
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3362
Mailing Address - Country:US
Mailing Address - Phone:703-878-7610
Mailing Address - Fax:703-878-7614
Practice Address - Street 1:2280 OPITZ BLVD
Practice Address - Street 2:SUITE 320
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3362
Practice Address - Country:US
Practice Address - Phone:703-878-7610
Practice Address - Fax:703-878-7614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102201710208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H66317Medicare UPIN
VAC09627Medicare ID - Type Unspecified