Basic Information
| Provider Information | |||||||||
| NPI: | 1770769515 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REDJAEE | ||||||||
| FirstName: | MARTA | ||||||||
| MiddleName: | MARYAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | REDJAEE | ||||||||
| OtherFirstName: | MARYAM | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 718 SMYTH RD | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031047007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036244366 | ||||||||
| FaxNumber: | 6036293268 | ||||||||
| Practice Location | |||||||||
| Address1: | 718 SMYTH RD | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031047007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036244366 | ||||||||
| FaxNumber: | 6036293268 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2008 | ||||||||
| LastUpdateDate: | 04/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 233901 | MA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 208D00000X | 61691-20 | WI | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.