Provider Demographics
NPI:1023094489
Name:MASHKOURI, MORTEZA (MD)
Entity type:Individual
Prefix:DR
First Name:MORTEZA
Middle Name:
Last Name:MASHKOURI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 616788
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32861-6788
Mailing Address - Country:US
Mailing Address - Phone:407-647-6070
Mailing Address - Fax:407-647-6440
Practice Address - Street 1:255 N LAKEMONT AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-3229
Practice Address - Country:US
Practice Address - Phone:407-647-6070
Practice Address - Fax:407-647-6440
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME48026207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265072000Medicaid
FLD51135Medicare UPIN
FL04924ZMedicare PIN