Healthcare Provider Details

I. General information

NPI: 1396765806
Provider Name (Legal Business Name): HORMAZDIAR DARA DASTOOR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 NAVY HILL RAD
SAIPAN MP
96950-0409
US

IV. Provider business mailing address

PO BOX 500409
SAIPAN MP
96950-0409
US

V. Phone/Fax

Practice location:
  • Phone: 670-323-0188
  • Fax:
Mailing address:
  • Phone: 670-323-0188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number00394
License Number StateMP

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: