Provider Demographics
NPI:1558331124
Name:SHAHBAZI, MANDANA (MD)
Entity Type:Individual
Prefix:
First Name:MANDANA
Middle Name:
Last Name:SHAHBAZI
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 1:25 MAIN STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136
Mailing Address - Country:US
Mailing Address - Phone:410-526-8310
Mailing Address - Fax:410-526-8316
Practice Address - Street 1:25 MAIN STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136
Practice Address - Country:US
Practice Address - Phone:410-526-8310
Practice Address - Fax:410-526-8316
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0063534207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD408809300Medicaid
MDH348M718Medicare ID - Type Unspecified
I43787Medicare UPIN