Provider Demographics
NPI:1073542239
Name:ZIDEHSARAI, MIRIAM (DO)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:ZIDEHSARAI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20455 LORAIN RD
Mailing Address - Street 2:SUITE T-01
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-3494
Mailing Address - Country:US
Mailing Address - Phone:440-799-4224
Mailing Address - Fax:440-799-4228
Practice Address - Street 1:224 W EXCHANGE ST
Practice Address - Street 2:SUITE 330
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44302-1704
Practice Address - Country:US
Practice Address - Phone:330-436-3150
Practice Address - Fax:330-436-3160
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.009607207RN0300X
IN02002822A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2947431Medicaid
OHH424220Medicare PIN
IN715530AWMedicare ID - Type Unspecified
IN200529620Medicaid
OHZI4267481Medicare PIN