Provider Demographics
NPI:1699767525
Name:SHIVAPOUR, E TORAGE (MD)
Entity type:Individual
Prefix:
First Name:E
Middle Name:TORAGE
Last Name:SHIVAPOUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:EZZATOLLAH
Other - Middle Name:
Other - Last Name:SHIVAPOUR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-356-7680
Mailing Address - Fax:319-356-4505
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-356-7680
Practice Address - Fax:319-356-4505
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA215552084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA48831OtherWELLMARK BCBS
IA2195321Medicaid
A14455Medicare UPIN
IA48831Medicare PIN