Provider Demographics
NPI:1417052754
Name:DEURELL, SHIDEH (MD)
Entity Type:Individual
Prefix:
First Name:SHIDEH
Middle Name:
Last Name:DEURELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 INDUSTRIAL DR
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03087-2021
Mailing Address - Country:US
Mailing Address - Phone:603-685-0150
Mailing Address - Fax:
Practice Address - Street 1:5 INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:NH
Practice Address - Zip Code:03087-2021
Practice Address - Country:US
Practice Address - Phone:603-685-0150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA7110208000000X
NH16192208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100509295Medicaid
NV100509295Medicaid