Provider Demographics
NPI:1134113103
Name:YAZDANI, MAHIN S (MD)
Entity Type:Individual
Prefix:MRS
First Name:MAHIN
Middle Name:S
Last Name:YAZDANI
Suffix:
Gender:F
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:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20639-0370
Mailing Address - Country:US
Mailing Address - Phone:410-535-1695
Mailing Address - Fax:410-535-8684
Practice Address - Street 1:2555 SOLOMONS ISLAND RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTOWN
Practice Address - State:MD
Practice Address - Zip Code:20639-8734
Practice Address - Country:US
Practice Address - Phone:410-535-1695
Practice Address - Fax:410-535-8684
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD17774207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD220291300Medicaid
406112094OtherMEDICARE RAILROAD
MD76450002OtherBC/BS MD
MD810924OtherMDIPA, OPTIMUM CHOICE
MD810924OtherMDIPA, OPTIMUM CHOICE
MD76450002OtherBC/BS MD
MD016L344AMedicare ID - Type Unspecified