Provider Demographics
NPI:1093958852
Name:MORTAZAVI SHEMIRANI, MARTIN MAZYAR (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:MAZYAR
Last Name:MORTAZAVI SHEMIRANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2100 LYNN RD STE 120
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-8033
Mailing Address - Country:US
Mailing Address - Phone:805-795-7656
Mailing Address - Fax:805-618-1501
Practice Address - Street 1:2100 LYNN RD STE 120
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-8033
Practice Address - Country:US
Practice Address - Phone:805-795-7656
Practice Address - Fax:805-618-1501
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-09
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA112672207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery