Provider Demographics
NPI:1053591271
Name:MORTEZA MIRHAIDARI D P M
Entity type:Organization
Organization Name:MORTEZA MIRHAIDARI D P M
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MORTEZA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRHAIDARI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:330-364-8884
Mailing Address - Street 1:152 NORTH BROADWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NEW PHILADELPHIA
Mailing Address - State:OH
Mailing Address - Zip Code:44663
Mailing Address - Country:US
Mailing Address - Phone:330-364-8884
Mailing Address - Fax:
Practice Address - Street 1:152 NORTH BROADWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:NEW PHILADELPHIA
Practice Address - State:OH
Practice Address - Zip Code:44663
Practice Address - Country:US
Practice Address - Phone:330-364-8884
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002348M213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCL5308OtherRAILROAD MEDICARE
OH0624793Medicaid
OH0624793Medicaid
OH0587174Medicare PIN