Provider Demographics
NPI:1194718452
Name:SIADATI, MOHAMMAD REZA (MD)
Entity type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:REZA
Last Name:SIADATI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 HALL JOHNSON RD STE 200
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-8766
Mailing Address - Country:US
Mailing Address - Phone:817-267-2678
Mailing Address - Fax:817-251-0039
Practice Address - Street 1:2050 HALL JOHNSON RD STE 200
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-8766
Practice Address - Country:US
Practice Address - Phone:817-267-2678
Practice Address - Fax:817-251-0039
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM9006208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX190036702Medicaid
IN200291960BMedicaid
TX190036701Medicaid
TX1F8231OtherMEDICARE
TX190036701Medicaid
INH28616Medicare UPIN
TX190036702Medicaid