MEDICARE: DR. SHAHED IZADDOOST MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	N9073	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386928562
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHAHED IZADDOOST MD

Provider Business Mailing Address
First Line	:	333 N SANTA ROSA ST
Second Line	:	SUITE D4023
City	:	SAN ANTONIO
State	:	TX
Zip	:	78207-3108
Country	:	US
Telephone Number	:	469-282-2711
Fax Number	:	469-282-2609

Provider Business Practice Location Address
First Line	:	1434 E SONTERRA BLVD STE 109
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-4972
Country	:	US
Telephone Number	:	210-479-3000
Fax Number	:	210-479-3016

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2011
Last Update Date	:	03/18/2019

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