Healthcare Provider Details

I. General information

NPI: 1154703585
Provider Name (Legal Business Name): SHADI RAZMDJOU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2015
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 RIDGELY AVE STE 201
ANNAPOLIS MD
21401-1083
US

IV. Provider business mailing address

621 RIDGELY AVE STE 201
ANNAPOLIS MD
21401-1083
US

V. Phone/Fax

Practice location:
  • Phone: 410-224-4887
  • Fax: 410-224-1428
Mailing address:
  • Phone: 410-224-4887
  • Fax: 410-224-1428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberD0092146
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: