Provider Demographics
NPI:1467581223
Name:SHAHBANDAR, HASSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:HASSAN
Middle Name:
Last Name:SHAHBANDAR
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 1:3913 W PROSPECT AVE
Mailing Address - Street 2:SUITE LL1
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-8798
Mailing Address - Country:US
Mailing Address - Phone:920-729-7105
Mailing Address - Fax:920-831-8306
Practice Address - Street 1:900 E GRANT ST
Practice Address - Street 2:E110
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-3487
Practice Address - Country:US
Practice Address - Phone:920-729-7105
Practice Address - Fax:920-739-2609
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18921207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31146500Medicaid
WI715250020Medicare PIN
WI260120009Medicare PIN
WI451850021Medicare PIN
WIB56529Medicare UPIN