1386928562 NPI number — DR. SHAHED IZADDOOST MD

Table of content: DR. SHAHED IZADDOOST MD (NPI 1386928562)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386928562 NPI number — DR. SHAHED IZADDOOST MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IZADDOOST
Provider First Name:
SHAHED
Provider Middle Name:
Provider Name Prefix Text:
DR.
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:
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:
1386928562
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
333 N SANTA ROSA ST
Provider Second Line Business Mailing Address:
SUITE D4023
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78207-3108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-282-2711
Provider Business Mailing Address Fax Number:
469-282-2609

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1434 E SONTERRA BLVD STE 109
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78258-4972
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-479-3000
Provider Business Practice Location Address Fax Number:
210-479-3016
Provider Enumeration Date:
10/05/2011

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:  N9073 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 327465602 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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