Provider Demographics
NPI:1013016674
Name:SOUDBAKHSH, MEHRAN (DC)
Entity Type:Individual
Prefix:DR
First Name:MEHRAN
Middle Name:
Last Name:SOUDBAKHSH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:MEHRAN
Other - Middle Name:
Other - Last Name:SOUDBAKHSH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:7509 FENCEROW ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89131-4546
Mailing Address - Country:US
Mailing Address - Phone:702-658-1681
Mailing Address - Fax:702-737-6390
Practice Address - Street 1:4325 N RANCHO DR
Practice Address - Street 2:#150
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3438
Practice Address - Country:US
Practice Address - Phone:702-658-1681
Practice Address - Fax:702-737-6390
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB716111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV3602012Medicaid
NV3602012Medicaid
NVU68520Medicare UPIN