Provider Demographics
NPI:1861472250
Name:HOSSEINI-DEHKORDI, MARYAM (MD)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:HOSSEINI-DEHKORDI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARYAM
Other - Middle Name:H
Other - Last Name:DEHKORDI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:6440 NICOLLET AVE
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-1613
Mailing Address - Country:US
Mailing Address - Phone:612-861-1622
Mailing Address - Fax:612-861-2307
Practice Address - Street 1:6440 NICOLLET AVE
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-1613
Practice Address - Country:US
Practice Address - Phone:612-861-1622
Practice Address - Fax:612-861-2307
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN36305207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN994025100Medicaid
F92252Medicare UPIN
MN994025100Medicaid
080004223Medicare ID - Type Unspecified