Provider Demographics
NPI:1013972736
Name:YAZDANFAR, SHAHRIAR (MD)
Entity Type:Individual
Prefix:
First Name:SHAHRIAR
Middle Name:
Last Name:YAZDANFAR
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:PO BOX 8500-8735
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-0001
Mailing Address - Country:US
Mailing Address - Phone:215-456-7000
Mailing Address - Fax:215-456-5926
Practice Address - Street 1:5401 OLD YORK RD
Practice Address - Street 2:KLEIN 404
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141
Practice Address - Country:US
Practice Address - Phone:215-456-7266
Practice Address - Fax:215-455-1933
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD034478L207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000695366Medicaid
B36809Medicare UPIN
0000109776Medicare ID - Type Unspecified