Provider Demographics
NPI:1700988441
Name:HEIDARIAN, NOSRATOLLAH SR (DPM)
Entity Type:Individual
Prefix:MR
First Name:NOSRATOLLAH
Middle Name:
Last Name:HEIDARIAN
Suffix:SR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9530 VISCOUNT STE 2P
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925
Mailing Address - Country:US
Mailing Address - Phone:915-591-4499
Mailing Address - Fax:915-591-3011
Practice Address - Street 1:9530 VISCOUNT STE 2P
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925
Practice Address - Country:US
Practice Address - Phone:915-591-4499
Practice Address - Fax:915-591-3011
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1043P213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4209016OtherAETNA
TXB19AOtherBLUE CROSS BLUE SHIELD
TX1104721036Medicaid
TXB19AOtherBLUE CROSS BLUE SHIELD
00B19AMedicare ID - Type Unspecified