Provider Demographics
NPI:1235135161
Name:MIRFENDERESKI, SEYED (MD)
Entity Type:Individual
Prefix:DR
First Name:SEYED
Middle Name:
Last Name:MIRFENDERESKI
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:PO BOX 391405
Mailing Address - Street 2:
Mailing Address - City:SOLON
Mailing Address - State:OH
Mailing Address - Zip Code:44039
Mailing Address - Country:US
Mailing Address - Phone:216-491-7660
Mailing Address - Fax:216-491-7662
Practice Address - Street 1:4180 WARRENSVILLE CTR RD.
Practice Address - Street 2:120A
Practice Address - City:WARRENSVILLE HTS
Practice Address - State:OH
Practice Address - Zip Code:44122
Practice Address - Country:US
Practice Address - Phone:216-491-7660
Practice Address - Fax:216-491-7662
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-24
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-07-2710-M207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2446651Medicaid
OH2446651Medicaid
G89776Medicare UPIN