Provider Demographics
NPI:1780814392
Name:SAHEBAZAMANI, MITRA (MD)
Entity type:Individual
Prefix:
First Name:MITRA
Middle Name:
Last Name:SAHEBAZAMANI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 NORTHWINDS PKWY
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-2280
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 GRESHAM DR STE 8630B
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1904
Practice Address - Country:US
Practice Address - Phone:757-388-6115
Practice Address - Fax:757-275-9998
Is Sole Proprietor?:No
Enumeration Date:2009-07-16
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA305532174400000X
IN01087805B207RC0200X
VA0101246269207RC0200X, 207RP1001X, 208M00000X
NC2018-02078207RP1001X
IN01087805A207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No174400000XOther Service ProvidersSpecialist
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1780814392Medicaid
NC19YH6OtherBCBS OF NC
VA1780814392Medicaid
NCNN4574BOtherMEDICARE