Provider Demographics
NPI:1093378267
Name:SHAZADEH SAFAVI, PEJMA
Entity Type:Individual
Prefix:
First Name:PEJMA
Middle Name:
Last Name:SHAZADEH SAFAVI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12023 POCATELLO DR
Mailing Address - Street 2:
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77377-3999
Mailing Address - Country:US
Mailing Address - Phone:714-768-9799
Mailing Address - Fax:
Practice Address - Street 1:4430 N HOLLAND SYLVANIA RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-2598
Practice Address - Country:US
Practice Address - Phone:714-768-9799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-15
Last Update Date:2021-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR77377208600000X
OH57.250597207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery