Provider Demographics
NPI:1174566731
Name:YAZDANI, SHAHRAM (MD)
Entity type:Individual
Prefix:
First Name:SHAHRAM
Middle Name:
Last Name:YAZDANI
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 1:8100 ASHTON AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-5688
Mailing Address - Country:US
Mailing Address - Phone:703-331-0300
Mailing Address - Fax:703-331-0300
Practice Address - Street 1:8100 ASHTON AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-5688
Practice Address - Country:US
Practice Address - Phone:703-331-0300
Practice Address - Fax:703-331-0300
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101226688207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA481437OtherOPT/MDIPA/MAMSI
VA5843278Medicaid
VA70670002OtherCAREFIRST PROVIDER NUMBER
VA2346100OtherAETNA HMO NUMBER
VA2501042OtherUNITEDHEALTH CARE NUMBER
VA5292653OtherAETNA PPO NUMBER
VA10029295Medicaid
VA541984220OtherTAX ID VIRGINIA CARDIO AS
VA216818OtherANTHEM PROVIDER NUMBER
VT562289471OtherTAX ID MANASSAS HEART
VAJ0600001OtherCAREFIRST
VA10390896OtherCAQH
VA1274643OtherCIGNA HMO PROVIDER NUMBER
VA461213OtherANTHEM FOR MANASSAS HEART
VA541984220OtherTAX ID VIRGINIA CARDIO AS
DCG00773Medicare ID - Type UnspecifiedGROUP DC MEDICARE
VA10029295Medicaid
VA00V165M83Medicare ID - Type UnspecifiedMEDICARE MANASSAS HEART
VA216818OtherANTHEM PROVIDER NUMBER
DC00A987V73Medicare ID - Type UnspecifiedDISTRICT OF COLUM MEDICAR