Provider Demographics
NPI:1679664544
Name:BAGHERZADEH-AZAR, MANILA (MD)
Entity Type:Individual
Prefix:
First Name:MANILA
Middle Name:
Last Name:BAGHERZADEH-AZAR
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 1:4301 W MARKHAM ST # 783
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-7101
Mailing Address - Country:US
Mailing Address - Phone:501-686-8000
Mailing Address - Fax:501-526-5148
Practice Address - Street 1:4301 W MARKHAM ST # 783
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7101
Practice Address - Country:US
Practice Address - Phone:501-686-8000
Practice Address - Fax:501-526-5148
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-40602085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARP00210259OtherRAILROAD MEDICARE
ARP00210259OtherRAILROAD MEDICARE
I27333Medicare UPIN