Provider Demographics
NPI:1386928562
Name:IZADDOOST, SHAHED (MD)
Entity type:Individual
Prefix:DR
First Name:SHAHED
Middle Name:
Last Name:IZADDOOST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:333 N SANTA ROSA ST
Mailing Address - Street 2:SUITE D4023
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-3108
Mailing Address - Country:US
Mailing Address - Phone:469-282-2711
Mailing Address - Fax:469-282-2609
Practice Address - Street 1:1434 E SONTERRA BLVD STE 109
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4972
Practice Address - Country:US
Practice Address - Phone:210-479-3000
Practice Address - Fax:210-479-3016
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-05
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN9073208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX327465602Medicaid