Provider Demographics
NPI:1366563959
Name:SHAHIDZADEH, RASSA (MD)
Entity type:Individual
Prefix:DR
First Name:RASSA
Middle Name:
Last Name:SHAHIDZADEH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4708 ALLIANCE BLVD
Mailing Address - Street 2:SUITE 300, BAYLOR MEDICAL PLAZA 1
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-5340
Mailing Address - Country:US
Mailing Address - Phone:972-758-6000
Mailing Address - Fax:972-758-6001
Practice Address - Street 1:4708 ALLIANCE BLVD
Practice Address - Street 2:SUITE 300, BAYLOR MEDICAL PLAZA 1
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5340
Practice Address - Country:US
Practice Address - Phone:972-758-6000
Practice Address - Fax:972-758-6001
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055794207RG0100X
TXL6176207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA055794OtherGEORGIA STATE LICENSE
TX202721101Medicaid
TX8BG110OtherBCBS
TX202721102Medicaid
TXL6176OtherTEXAS STATE LICENSE
TXL6176OtherTEXAS STATE LICENSE
TX202721101Medicaid