Provider Demographics
NPI:1063647857
Name:ALIZADEGAN, SHAHRIAR (MD)
Entity Type:Individual
Prefix:
First Name:SHAHRIAR
Middle Name:
Last Name:ALIZADEGAN
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 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:VASCULAR SURGERY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-8620
Mailing Address - Fax:414-454-0152
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:VASCULAR SURGERY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-8620
Practice Address - Fax:414-454-0152
Is Sole Proprietor?:No
Enumeration Date:2009-05-21
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI62270208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1063647857Medicaid
WI1063647857Medicaid