Healthcare Provider Details

I. General information

NPI: 1689023186
Provider Name (Legal Business Name): SASAN MOSHIRZADEH M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 W 10TH ST
ROLLA MO
65401-2905
US

IV. Provider business mailing address

1050 W 10TH ST
ROLLA MO
65401-2905
US

V. Phone/Fax

Practice location:
  • Phone: 573-364-9000
  • Fax: 573-202-2484
Mailing address:
  • Phone: 573-364-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number69045
License Number StateMN

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: