Provider Demographics
NPI:1205272986
Name:WALIZADA, SHAHLA (DO)
Entity type:Individual
Prefix:
First Name:SHAHLA
Middle Name:
Last Name:WALIZADA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SHAHLA
Other - Middle Name:
Other - Last Name:NOORI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-302-5000
Mailing Address - Fax:208-302-5025
Practice Address - Street 1:2141 E PARKCENTER BLVD
Practice Address - Street 2:SAMG BHP FAMILY MEDICINE
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-302-5000
Practice Address - Fax:208-302-5025
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-21
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO0953207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine