Healthcare Provider Details

I. General information

NPI: 1528014974
Provider Name (Legal Business Name): MAHBOUBEH DADASH ZADEH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 GREEN ACRE ROAD
TOWSON MD
21286
US

IV. Provider business mailing address

1109 GREEN ACRE RD
TOWSON MD
21286-1734
US

V. Phone/Fax

Practice location:
  • Phone: 410-821-1912
  • Fax:
Mailing address:
  • Phone: 410-821-1912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD32153
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierB70685
Identifier TypeOTHER
Identifier StateMD
Identifier IssuerUPIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: