Provider Demographics
NPI:1528295854
Name:EDALAT, FARAMARZ (MD)
Entity type:Individual
Prefix:DR
First Name:FARAMARZ
Middle Name:
Last Name:EDALAT
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 1:2629 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53083-4932
Mailing Address - Country:US
Mailing Address - Phone:920-451-5000
Mailing Address - Fax:
Practice Address - Street 1:1364 CLIFTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322
Practice Address - Country:US
Practice Address - Phone:404-712-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-13
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0821482085R0204X
WI677772085R0204X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology