Provider Demographics
NPI:1962436956
Name:DARIOUSH NASSERI MD PA
Entity type:Organization
Organization Name:DARIOUSH NASSERI MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHOPAEDIC SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:DARIOUSH
Authorized Official - Middle Name:
Authorized Official - Last Name:NASSERI
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:410-435-8100
Mailing Address - Street 1:5601 LOCH RAVEN BLVD
Mailing Address - Street 2:STE G2
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21239-2905
Mailing Address - Country:US
Mailing Address - Phone:410-435-8100
Mailing Address - Fax:443-444-4830
Practice Address - Street 1:5601 LOCH RAVEN BLVD
Practice Address - Street 2:STE G2
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21239-2905
Practice Address - Country:US
Practice Address - Phone:410-435-8100
Practice Address - Fax:443-444-4830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2011-09-20
Deactivation Date:2011-08-03
Deactivation Code:
Reactivation Date:2011-09-20
Provider Licenses
StateLicense IDTaxonomies
MDD0026027207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD772491800Medicaid
MD412MMedicare PIN
B66856Medicare UPIN