Provider Demographics
NPI:1033138011
Name:SIADATI, ABDOLREZA (MD)
Entity Type:Individual
Prefix:
First Name:ABDOLREZA
Middle Name:
Last Name:SIADATI
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 1:1900 MISTLETOE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4049
Mailing Address - Country:US
Mailing Address - Phone:817-878-5333
Mailing Address - Fax:817-878-5334
Practice Address - Street 1:1900 MISTLETOE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4014
Practice Address - Country:US
Practice Address - Phone:817-878-5333
Practice Address - Fax:817-878-5334
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8956207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8C1291Medicare ID - Type UnspecifiedMEDICARE ID NUMBER
TXI11339Medicare UPIN