Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207T00000X | Neurosurgeon | L8956 | TX |
NPI | 1033138011 |
---|---|
Provider Name | Abdolreza Siadati |
First Address | Fort Worth, TX 76104-4049 |
Second Address | Fort Worth, TX 76104-4014 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/07/2006 |
Last Update Date | 04/02/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
I11339 | (02) | TX |