Provider Demographics
NPI:1780210617
Name:SADOUGH SHAHMIRZADI, MARYAM (MD)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:SADOUGH SHAHMIRZADI
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 1:4340 CLEARWATER RD APT 116
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-9642
Mailing Address - Country:US
Mailing Address - Phone:415-525-0390
Mailing Address - Fax:
Practice Address - Street 1:4340 CLEARWATER RD APT 116
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-9642
Practice Address - Country:US
Practice Address - Phone:415-525-0390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-23
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program