Healthcare Provider Details

I. General information

NPI: 1710062245
Provider Name (Legal Business Name): SHAHRIYAR A LEILABADI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9924 NE 185TH ST
BOTHELL WA
98011-3502
US

IV. Provider business mailing address

PO BOX 5127
EVERETT WA
98206-5127
US

V. Phone/Fax

Practice location:
  • Phone: 425-595-3830
  • Fax: 425-595-3831
Mailing address:
  • Phone: 425-304-8431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number242080
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD60556970
License Number StateWA

VII. Legacy identifiers

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

# 1
Identifier061129000052
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerFIDELIS CARE #
# 2
Identifier2087778
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer
# 3
Identifier000528841001
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerHEALTH NOW BCBS #
# 4
Identifier070320000059
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerFIDELIS CARE URGENT CARE#
# 5
Identifier00027738401
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerUNIVERA #
# 6
Identifier0145379
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerGHI PPO #
# 7
Identifier194882BF
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerPREFERRED CARE #
# 8
Identifier0114050
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerIHA #

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: