Provider Demographics
NPI:1043423775
Name:MAHALLATI-SHIRAZI, AHMAD (MD)
Entity Type:Individual
Prefix:
First Name:AHMAD
Middle Name:
Last Name:MAHALLATI-SHIRAZI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:AHMAD
Other - Middle Name:
Other - Last Name:MAHALLATI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1100 NINTH AVENUE
Mailing Address - Street 2:C7-NEPH
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98111
Mailing Address - Country:US
Mailing Address - Phone:206-223-6673
Mailing Address - Fax:
Practice Address - Street 1:1100 9TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2756
Practice Address - Country:US
Practice Address - Phone:202-223-6673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60221637207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1043423775Medicaid
MDS062-0323OtherBLUE CROSS/BLUE SHIELD REGIONAL
MD925031-01OtherBLUE CROSS/BLUE SHIELD
MD413127400Medicaid
WAP00981400OtherRAILROAD MEDICARE
MD413127400Medicaid
WA8905633Medicare PIN
WA1043423775Medicaid
WA8903522Medicare PIN
MD925031-01OtherBLUE CROSS/BLUE SHIELD