Healthcare Provider Details

I. General information

NPI: 1962792515
Provider Name (Legal Business Name): SHAYDA MIRHAIDARI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2011
Last Update Date: 06/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4466 FULTON DR NW
CANTON OH
44718-2864
US

IV. Provider business mailing address

3925 EMBASSY PKWY STE 300
AKRON OH
44333-1799
US

V. Phone/Fax

Practice location:
  • Phone: 330-668-4065
  • Fax: 330-668-4082
Mailing address:
  • Phone: 330-668-4065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number35.128792
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: