Provider Demographics
NPI:1275535742
Name:HADJBIAN, EHSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:EHSAN
Middle Name:
Last Name:HADJBIAN
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 1:909 E 9400 S
Mailing Address - Street 2:SUITE C
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-5514
Mailing Address - Country:US
Mailing Address - Phone:801-748-0580
Mailing Address - Fax:801-748-2274
Practice Address - Street 1:909 E 9400 S
Practice Address - Street 2:SUITE C
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-5514
Practice Address - Country:US
Practice Address - Phone:801-748-0580
Practice Address - Fax:801-748-2274
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5266556-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTH 99193Medicare UPIN
UT005778801Medicare ID - Type Unspecified