Basic Information
| Provider Information | |||||||||
| NPI: | 1932426095 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ASSADIPOUR | ||||||||
| FirstName: | YASMINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 37174 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212973174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5714235699 | ||||||||
| FaxNumber: | 5714235698 | ||||||||
| Practice Location | |||||||||
| Address1: | 13135 LEE JACKSON MEMORIAL HWY STE 305 | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220331907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033598640 | ||||||||
| FaxNumber: | 7035916105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2010 | ||||||||
| LastUpdateDate: | 10/31/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | A148367 | CA | N | Allopathic & Osteopathic Physicians | Surgery | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208600000X | 0101264961 | VA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1932426095 | 05 | VA | MEDICAID |