Basic Information
Provider Information | |||||||||
NPI: | 1568758951 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JAZINI | ||||||||
FirstName: | EHSAN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11800 SUNRISE VALLEY DR STE 600 | ||||||||
Address2: |   | ||||||||
City: | RESTON | ||||||||
State: | VA | ||||||||
PostalCode: | 201915327 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7037091114 | ||||||||
FaxNumber: | 7037091117 | ||||||||
Practice Location | |||||||||
Address1: | 11800 SUNRISE VALLEY DR STE 600 | ||||||||
Address2: |   | ||||||||
City: | RESTON | ||||||||
State: | VA | ||||||||
PostalCode: | 20191 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7037091114 | ||||||||
FaxNumber: | 7037091117 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2011 | ||||||||
LastUpdateDate: | 03/02/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/02/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 49233 | KY | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207X00000X | 0101262789 | VA | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207XS0117X | 0101262789 | VA | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
ID Information
ID | Type | State | Issuer | Description | 7100422590 | 05 | KY |   | MEDICAID | 201379230 | 05 | KY |   | MEDICAID | 870300100 | 05 | MD |   | MEDICAID | 017293178 | 05 | DC |   | MEDICAID |