Provider Demographics
NPI:1902903701
Name:SHAYESTEH, AMID (DO)
Entity Type:Individual
Prefix:
First Name:AMID
Middle Name:
Last Name:SHAYESTEH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 REID PARKWAY
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1157
Mailing Address - Country:US
Mailing Address - Phone:765-935-8807
Mailing Address - Fax:765-983-3219
Practice Address - Street 1:1100 REID PARKWAY
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1157
Practice Address - Country:US
Practice Address - Phone:765-983-3144
Practice Address - Fax:765-983-3038
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001165A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000031530OtherBLUE SHIELD - REID HOSP
OH085200Medicaid
IN100367840Medicaid
IN000000031530OtherBLUE SHIELD - REID HOSP
IN100367840Medicaid
OH085200Medicaid