Provider Demographics
NPI:1922198183
Name:GOLESORKHI, REZA (MD)
Entity type:Individual
Prefix:
First Name:REZA
Middle Name:
Last Name:GOLESORKHI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:REZA
Other - Middle Name:
Other - Last Name:GOLESORKHI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:12506 LAKE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192
Mailing Address - Country:US
Mailing Address - Phone:703-494-6111
Mailing Address - Fax:703-497-0476
Practice Address - Street 1:12506 LAKE RIDGE DR
Practice Address - Street 2:C
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192
Practice Address - Country:US
Practice Address - Phone:703-494-6111
Practice Address - Fax:703-497-0476
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAB101233727207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5885264Medicaid
VA00W591W01Medicare ID - Type Unspecified
H80292Medicare UPIN