Provider Demographics
NPI:1992774533
Name:FOROOGH-NASSIRAEE, MITRA (MD)
Entity type:Individual
Prefix:DR
First Name:MITRA
Middle Name:
Last Name:FOROOGH-NASSIRAEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MITRA
Other - Middle Name:
Other - Last Name:FOROOGH NASSIRAEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:26005 RIDGE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:DAMASCUS
Mailing Address - State:MD
Mailing Address - Zip Code:20872-1899
Mailing Address - Country:US
Mailing Address - Phone:301-414-2300
Mailing Address - Fax:301-414-0476
Practice Address - Street 1:7620 CARROLL AVE STE 201
Practice Address - Street 2:
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-6388
Practice Address - Country:US
Practice Address - Phone:018-916-6473
Practice Address - Fax:301-891-6654
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0060745207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD402938100Medicaid
MD402938100Medicaid
MD407MO741Medicare PIN
MD168937ZFBKMedicare PIN