Provider Demographics
NPI:1205569514
Name:HEIDARI, BASHIR (MD)
Entity type:Individual
Prefix:DR
First Name:BASHIR
Middle Name:
Last Name:HEIDARI
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 1:333 BORTHWICK AVE
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-7128
Mailing Address - Country:US
Mailing Address - Phone:303-563-9790
Mailing Address - Fax:
Practice Address - Street 1:311 ROUTE 108
Practice Address - Street 2:
Practice Address - City:SOMERSWORTH
Practice Address - State:NH
Practice Address - Zip Code:03878-1522
Practice Address - Country:US
Practice Address - Phone:603-749-2346
Practice Address - Fax:603-953-0066
Is Sole Proprietor?:No
Enumeration Date:2022-07-05
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHR4046390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program