Provider Demographics
NPI:1205053113
Name:BEHESHTI SHIRAZI, SEYED ABDOLJAVAD (MD)
Entity type:Individual
Prefix:
First Name:SEYED ABDOLJAVAD
Middle Name:
Last Name:BEHESHTI SHIRAZI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JAVAD
Other - Middle Name:
Other - Last Name:BEHESHTI SHIRAZI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:1 GUTHRIE DR
Practice Address - Street 2:DEPARTMENT OF PATHOLOGY
Practice Address - City:CORNING
Practice Address - State:NY
Practice Address - Zip Code:14830-3696
Practice Address - Country:US
Practice Address - Phone:607-937-1451
Practice Address - Fax:607-937-7860
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD453997207ZP0101X, 207ZD0900X
NY268155-1207ZP0101X
NY268188207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03536096Medicaid
NYJ400199653Medicare PIN
PA402325N8WMedicare PIN