1710062245 NPI number — SHAHRIYAR A LEILABADI MD

Table of content: SHAHRIYAR A LEILABADI MD (NPI 1710062245)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710062245 NPI number — SHAHRIYAR A LEILABADI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEILABADI
Provider First Name:
SHAHRIYAR
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1710062245
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5127
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVERETT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98206-5127
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-304-8431
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9924 NE 185TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOTHELL
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98011-3502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-595-3830
Provider Business Practice Location Address Fax Number:
425-595-3831
Provider Enumeration Date:
10/25/2006

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: 207Q00000X , with the licence number:  242080 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: MD60556970 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 061129000052 . This is a "FIDELIS CARE #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2087778 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000528841001 . This is a "HEALTH NOW BCBS #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 070320000059 . This is a "FIDELIS CARE URGENT CARE#" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00027738401 . This is a "UNIVERA #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0145379 . This is a "GHI PPO #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 194882BF . This is a "PREFERRED CARE #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0114050 . This is a "IHA #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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