Provider Demographics
NPI:1699030635
Name:ZANDNIA, SHAHROOZ (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAHROOZ
Middle Name:
Last Name:ZANDNIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 169TH ST S
Mailing Address - Street 2:STE A
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-8201
Mailing Address - Country:US
Mailing Address - Phone:253-538-4660
Mailing Address - Fax:253-538-4675
Practice Address - Street 1:144 169TH ST S
Practice Address - Street 2:STE A
Practice Address - City:SPANAWAY
Practice Address - State:WA
Practice Address - Zip Code:98387-8201
Practice Address - Country:US
Practice Address - Phone:253-538-4660
Practice Address - Fax:253-538-4675
Is Sole Proprietor?:No
Enumeration Date:2012-07-05
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAMD60599379207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8955121Medicare PIN