Basic Information
| Provider Information | |||||||||
| NPI: | 1831416510 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YEZDANI | ||||||||
| FirstName: | MONA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 FOULK RD STE F | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198103642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026528990 | ||||||||
| FaxNumber: | 3026528646 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 FOULK RD STE F | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198103642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026528990 | ||||||||
| FaxNumber: | 3026528646 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2010 | ||||||||
| LastUpdateDate: | 09/25/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | MD454801 | PA | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | C10011732 | DE | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 200172053 | 05 | DE | MEDICAID |