Provider Demographics
NPI:1447726096
Name:MARDANZAI, MASOOD MEHDI
Entity type:Individual
Prefix:MR
First Name:MASOOD
Middle Name:MEHDI
Last Name:MARDANZAI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2195 CLEAR LAKE CT
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95304-5827
Mailing Address - Country:US
Mailing Address - Phone:209-609-4648
Mailing Address - Fax:
Practice Address - Street 1:2195 CLEAR LAKE CT
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95304-5827
Practice Address - Country:US
Practice Address - Phone:209-609-4648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31865227800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified