Provider Demographics
NPI:1659567758
Name:DAVANLOO, HEDIEH (MD)
Entity Type:Individual
Prefix:
First Name:HEDIEH
Middle Name:
Last Name:DAVANLOO
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 1:809 W RANDOL MILL RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012-2507
Mailing Address - Country:US
Mailing Address - Phone:817-277-7133
Mailing Address - Fax:817-274-6367
Practice Address - Street 1:809 W RANDOL MILL RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-2507
Practice Address - Country:US
Practice Address - Phone:817-277-7133
Practice Address - Fax:817-274-6367
Is Sole Proprietor?:No
Enumeration Date:2007-09-21
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM7933207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX19345073OtherMEDICAID - OTHER
TX8X9564OtherBCBS
TX193450701Medicaid
TX193450704OtherMEDICAID - TARRANT
TXP00642499OtherRAILROAD MEDICARE
TX193450705OtherMEDICAID - DALLAS
TX193450705OtherMEDICAID - DALLAS