# LAKE RIDGE ANESTHESIA LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1558619254
- **Authorized official:** REZA IZADI DO (OWNER)
- **Authorized official phone:** (301) 829-7683

## Contact information

- **Practice address:** 12825 MINNIEVILLE ROAD, \# 220, WOODBRIDGE, VA 22192
- **Practice address phone:** (301) 829-7386
- **Practice address fax:** (301) 829-7694
- **Mailing address:** 1302 RISING RIDGE RD, \# 1, MOUNT AIRY, MD 21771-5790
- **Mailing address phone:** (301) 829-7683
- **Mailing address fax:** (301) 829-7694

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207L00000X | Anesthesiology Physician | 0101237760 | VA | Yes |
| 207LP2900X | Pain Medicine (Anesthesiology) Physician | 0101237760 | VA | — |

## Other

- **Enumeration date:** 08/28/2012
- **Last updated:** 08/19/2015