Provider Demographics
NPI:1639179146
Name:MOAZAMI, SHOHREH IV (MD)
Entity Type:Individual
Prefix:DR
First Name:SHOHREH
Middle Name:
Last Name:MOAZAMI
Suffix:IV
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2545 CAPITAL AVE SW
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015-7120
Mailing Address - Country:US
Mailing Address - Phone:269-969-8723
Mailing Address - Fax:269-969-8724
Practice Address - Street 1:2545 CAPITAL AVE SW
Practice Address - Street 2:SUITE 201
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015-7120
Practice Address - Country:US
Practice Address - Phone:269-969-8723
Practice Address - Fax:269-969-8724
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301062801208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5922108OtherAETNA
MI00994OtherHEALTH PLAN OF MICHIGAN
MI3501310791OtherBLUE CROSS BLUE SHEILD
MI12-31350OtherUNITED HEALTH CARE
MI147687OtherGREAT LAKES HEALTH PLAN
MI00994OtherHEALTH PLAN OF MICHIGAN