Basic Information
Provider Information | |||||||||
NPI: | 1922427509 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HEDAYAT | ||||||||
FirstName: | AMIN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D., FASCP, FCAP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1201 S COLLEGEVILLE RD | ||||||||
Address2: |   | ||||||||
City: | COLLEGEVILLE | ||||||||
State: | PA | ||||||||
PostalCode: | 194262998 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6104546146 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4230 BURNHAM AVE | ||||||||
Address2: |   | ||||||||
City: | LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 891195408 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9494666096 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/10/2014 | ||||||||
LastUpdateDate: | 12/20/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/20/2019 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0900X | 19023 | NV | N |   | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207ZD0900X | 19023 | NV | Y |   | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology |
No ID Information.