Provider Demographics
NPI:1033197165
Name:MANSHADI, FARID FREDERICK (MD)
Entity Type:Individual
Prefix:
First Name:FARID
Middle Name:FREDERICK
Last Name:MANSHADI
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 1:36 W PARK LN
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50701-5178
Mailing Address - Country:US
Mailing Address - Phone:319-234-0109
Mailing Address - Fax:
Practice Address - Street 1:36 W PARK LN
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-5178
Practice Address - Country:US
Practice Address - Phone:319-234-0109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA27493208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA250004438OtherRR MEDICARE
IA044982OtherBC/BS
IAA006219OtherCHAMPUS
IA0298216Medicaid
IA42137207602OtherJOHN DEERE
IA04498Medicare ID - Type Unspecified
IAA006219OtherCHAMPUS