Provider Demographics
NPI:1184689143
Name:MOHTADI, NADER R (MD)
Entity Type:Individual
Prefix:DR
First Name:NADER
Middle Name:R
Last Name:MOHTADI
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 1:5333 MCAULEY DR
Mailing Address - Street 2:SUITE 6016
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1014
Mailing Address - Country:US
Mailing Address - Phone:734-712-8350
Mailing Address - Fax:734-712-8351
Practice Address - Street 1:5333 MCAULEY DR
Practice Address - Street 2:SUITE 6016
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1014
Practice Address - Country:US
Practice Address - Phone:734-712-8350
Practice Address - Fax:734-712-8351
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010559782085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3516137Medicaid
MIF85554Medicare UPIN
MIOM74400001Medicare ID - Type Unspecified