1205963725 NPI number — DR. HOOSHANG SHANEHSAZ RPH

Table of content: DR. HOOSHANG SHANEHSAZ RPH (NPI 1205963725)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205963725 NPI number — DR. HOOSHANG SHANEHSAZ RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHANEHSAZ
Provider First Name:
HOOSHANG
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
RPH
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205963725
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
784 NAULT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOVER
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19904-5808
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-734-9707
Provider Business Mailing Address Fax Number:
302-223-1090

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 SUNNYSIDE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SMYRNA
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19977-1752
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-223-1370
Provider Business Practice Location Address Fax Number:
302-223-1090
Provider Enumeration Date:
02/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1835P1200X , with the licence number:  A1-0002127 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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