Basic Information
| Provider Information | |||||||||
| NPI: | 1134198955 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIRAZI | ||||||||
| FirstName: | MANOUCHER | ||||||||
| MiddleName: | SHADMAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 WILLIAMS ST | ||||||||
| Address2: | |||||||||
| City: | ANDOVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9784753324 | ||||||||
| FaxNumber: | 9782759552 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 RESEARCH PLACE | ||||||||
| Address2: | |||||||||
| City: | N CHELMSFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018632439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9782759650 | ||||||||
| FaxNumber: | 9782759552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2006 | ||||||||
| LastUpdateDate: | 08/17/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 32933 | MA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2030497 | 05 | MA | MEDICAID |