Provider Demographics
NPI:1720157647
Name:EHSANI-SHISHVAN, HAMID (MD)
Entity Type:Individual
Prefix:DR
First Name:HAMID
Middle Name:
Last Name:EHSANI-SHISHVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:HAMID
Other - Middle Name:
Other - Last Name:EHSANI-SHISHVAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 64362
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4362
Mailing Address - Country:US
Mailing Address - Phone:410-550-5177
Mailing Address - Fax:
Practice Address - Street 1:4940 EASTERN AVE
Practice Address - Street 2:JOHNS HOPKINS BAYVIEW MEDICAL CENTER, DEP ER , BLG B2
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-2735
Practice Address - Country:US
Practice Address - Phone:410-550-5177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301083403207Q00000X
MDD0065701207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD0065701OtherSTATE LICENSE
MI4301083403OtherPHYSICIAN
MDS806Q116Medicare PIN
MI4301083403OtherPHYSICIAN