Provider Demographics
NPI:1275514127
Name:SHAHIDEH, ASADOLLAH (MD)
Entity Type:Individual
Prefix:DR
First Name:ASADOLLAH
Middle Name:
Last Name:SHAHIDEH
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 1:5155 NORKO DR
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-3021
Mailing Address - Country:US
Mailing Address - Phone:810-720-6700
Mailing Address - Fax:810-230-7764
Practice Address - Street 1:4792 ROCHESTER RD
Practice Address - Street 2:STE A
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-4929
Practice Address - Country:US
Practice Address - Phone:248-528-9010
Practice Address - Fax:248-528-2162
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301035596207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1094629Medicaid
D72831Medicare UPIN
06372858Medicare ID - Type Unspecified
MI1094629Medicaid