Provider Demographics
NPI:1396774139
Name:ABBASSI, SHAHRAM (MD)
Entity type:Individual
Prefix:
First Name:SHAHRAM
Middle Name:
Last Name:ABBASSI
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 725
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:95524-0725
Mailing Address - Country:US
Mailing Address - Phone:707-822-7220
Mailing Address - Fax:707-633-6086
Practice Address - Street 1:3800 JANES RD
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-4742
Practice Address - Country:US
Practice Address - Phone:707-822-3621
Practice Address - Fax:707-633-6086
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51286207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00001256807008Medicaid
PA685174OtherHIGHMARK BCBS
PAAB685174Medicare ID - Type Unspecified
PA685174OtherHIGHMARK BCBS