Provider Demographics
NPI:1194726851
Name:BOZORGZADEH, SHAHRIAR (MD)
Entity type:Individual
Prefix:
First Name:SHAHRIAR
Middle Name:
Last Name:BOZORGZADEH
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:PO BOX 1467
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1467
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:618-529-0586
Practice Address - Street 1:1050 LAKEWAY DR
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98229-2020
Practice Address - Country:US
Practice Address - Phone:360-746-6531
Practice Address - Fax:360-746-6266
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60114769207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3932056OtherBLUE SHIELD
IL0360096984Medicaid
IL036096984Medicaid
IL036096984Medicaid
IL3932056OtherBLUE SHIELD
IL0360096984Medicaid