Provider Demographics
NPI:1871740241
Name:MORTAZAVI, MOHAMMED (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMMED
Middle Name:
Last Name:MORTAZAVI
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 1:5199 E FARNESS DR STE 101
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2262
Mailing Address - Country:US
Mailing Address - Phone:520-222-8076
Mailing Address - Fax:520-300-7156
Practice Address - Street 1:5199 E FARNESS DR STE 101
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712
Practice Address - Country:US
Practice Address - Phone:520-222-8076
Practice Address - Fax:520-300-7156
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ494212080S0010X, 2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ923231Medicaid
AZ1871740241OtherNPI
AZ923231Medicaid