Provider Demographics
NPI:1598775280
Name:MIRHAIDARI, MORTEZA (DPM, MD)
Entity Type:Individual
Prefix:DR
First Name:MORTEZA
Middle Name:
Last Name:MIRHAIDARI
Suffix:
Gender:M
Credentials:DPM, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 N BROADWAY ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NEW PHILADELPHIA
Mailing Address - State:OH
Mailing Address - Zip Code:44663-2665
Mailing Address - Country:US
Mailing Address - Phone:330-364-8884
Mailing Address - Fax:330-602-5747
Practice Address - Street 1:152 N BROADWAY ST
Practice Address - Street 2:SUITE 100
Practice Address - City:NEW PHILADELPHIA
Practice Address - State:OH
Practice Address - Zip Code:44663-2665
Practice Address - Country:US
Practice Address - Phone:330-364-8884
Practice Address - Fax:330-440-7038
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.002348213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0624793Medicaid
OH480005452OtherRAILROAD MEDICARE
OH0587174Medicare PIN
OH0624793Medicaid
OH5029250001Medicare NSC