Basic Information
| Provider Information | |||||||||
| NPI: | 1497907273 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IZADYAR | ||||||||
| FirstName: | SHAHRAM | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 PRESIDENTIAL PLZ | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132022240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154644243 | ||||||||
| FaxNumber: | 3154645350 | ||||||||
| Practice Location | |||||||||
| Address1: | 90 PRESIDENTIAL PLZ | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132022240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154644243 | ||||||||
| FaxNumber: | 3154645350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2008 | ||||||||
| LastUpdateDate: | 08/21/2013 | ||||||||
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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 | 2084N0600X | 264552 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 2084N0400X | 264552 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 03462140 | 05 | NY | MEDICAID |