Provider Demographics
NPI:1407943921
Name:TRISTANI-FIROUZI, PAYAM (MD)
Entity Type:Individual
Prefix:DR
First Name:PAYAM
Middle Name:
Last Name:TRISTANI-FIROUZI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:PAYAM
Other - Middle Name:
Other - Last Name:TRISTANI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1055 N 500 W ATTN: CREDENTIALING
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:1055 N 500 W STE 111
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3305
Practice Address - Country:US
Practice Address - Phone:801-374-8999
Practice Address - Fax:801-429-8063
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3496681205207ND0101X, 207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology