Provider Demographics
NPI:1316009046
Name:HEYDARPOUR, MEHRAN (MD)
Entity Type:Individual
Prefix:
First Name:MEHRAN
Middle Name:
Last Name:HEYDARPOUR
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 1413
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53008-1413
Mailing Address - Country:US
Mailing Address - Phone:262-780-0770
Mailing Address - Fax:
Practice Address - Street 1:19475 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-4199
Practice Address - Country:US
Practice Address - Phone:262-780-0770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30408207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F15348Medicare UPIN