Provider Demographics
NPI:1396875910
Name:IZADDOOST, SHAYESTEH MARYAM (OD)
Entity type:Individual
Prefix:MISS
First Name:SHAYESTEH
Middle Name:MARYAM
Last Name:IZADDOOST
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2480 LLEWELLYN AVE
Mailing Address - Street 2:
Mailing Address - City:FORT GEORGE G MEADE
Mailing Address - State:MD
Mailing Address - Zip Code:20755-7081
Mailing Address - Country:US
Mailing Address - Phone:301-677-8950
Mailing Address - Fax:
Practice Address - Street 1:2480 LLEWELLYN AVE
Practice Address - Street 2:
Practice Address - City:FORT GEORGE G MEADE
Practice Address - State:MD
Practice Address - Zip Code:20755-7081
Practice Address - Country:US
Practice Address - Phone:301-677-8950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002983152W00000X
TX7031TG152W00000X
GAOPT002693152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7031TGOtherLICENSE (THERA GLAUC)