MEDICARE: MAHDIYEH SHAHPASANDZADEH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1467987040
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAHDIYEH SHAHPASANDZADEH

Provider Business Mailing Address
First Line	:	2339 HUDSON TER
Second Line	:	APT B3
City	:	FORT LEE
State	:	NJ
Zip	:	07024-7930
Country	:	US
Telephone Number	:	310-977-8748
Fax Number	:

Provider Business Practice Location Address
First Line	:	2339 HUDSON TER
Second Line	:	APT B3
City	:	FORT LEE
State	:	NJ
Zip	:	07024-7930
Country	:	US
Telephone Number	:	310-977-8748
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/20/2017
Last Update Date	:	04/20/2017

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