Organization
LAKE RIDGE ANESTHESIA LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
REZA IZADI DO (OWNER)
(301) 829-7683
Entity
Organization
Contact information
Practice address
12825 MINNIEVILLE ROAD, # 220, WOODBRIDGE, VA 22192
(301) 829-7386
(301) 829-7694
Mailing address
1302 RISING RIDGE RD, # 1, MOUNT AIRY, MD 21771-5790
(301) 829-7683
(301) 829-7694
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
0101237760
VA
207LP2900X
Pain Medicine (Anesthesiology) Physician
0101237760
VA
Other
Enumeration date
08/28/2012
Last updated
08/19/2015
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