1871571943 NPI number — MRS. SHIRIN MAHOOTI MD

Table of content: MRS. SHIRIN MAHOOTI MD (NPI 1871571943)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871571943 NPI number — MRS. SHIRIN MAHOOTI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAHOOTI
Provider First Name:
SHIRIN
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
AZARI
Provider Other First Name:
SHIRIN
Provider Other Middle Name:
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1871571943
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1389 W MAIN ST
Provider Second Line Business Mailing Address:
TOWER 1, SUITE 207
Provider Business Mailing Address City Name:
WATERBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06708-3104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-574-4473
Provider Business Mailing Address Fax Number:
203-574-4953

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1389 W MAIN ST
Provider Second Line Business Practice Location Address:
TOWER 1, SUITE 207
Provider Business Practice Location Address City Name:
WATERBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06708-3104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-574-4473
Provider Business Practice Location Address Fax Number:
203-574-4953
Provider Enumeration Date:
01/09/2006

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: 208000000X , with the licence number:  02110 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00122110000 . This is a "BLUE CARE FAMILY PLAN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 745722 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: OR2032 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 010022110CT01 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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