Basic Information
| Provider Information | |||||||||
| NPI: | 1992774533 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOROOGH-NASSIRAEE | ||||||||
| FirstName: | MITRA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FOROOGH NASSIRAEE | ||||||||
| OtherFirstName: | MITRA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 26005 RIDGE RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | DAMASCUS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208721899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014142300 | ||||||||
| FaxNumber: | 3014140476 | ||||||||
| Practice Location | |||||||||
| Address1: | 7620 CARROLL AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | TAKOMA PARK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209126388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0189166473 | ||||||||
| FaxNumber: | 3018916654 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 04/24/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | D0060745 | MD | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 402938100 | 05 | MD | MEDICAID |