Provider Demographics
NPI:1902396021
Name:YAZDAN, ANTORA (DO)
Entity Type:Individual
Prefix:
First Name:ANTORA
Middle Name:
Last Name:YAZDAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5620 AGER RD STE 2312
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20782-3729
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:KAISER PERMANENTE WEST HYATTSVILLE MEDICAL CENTER
Practice Address - Street 2:5620 AGER RD
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20782
Practice Address - Country:US
Practice Address - Phone:800-777-7904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDH91414207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program