Provider Demographics
NPI:1225138423
Name:MOKHTARI, SUSAN (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MOKHTARI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:BAYAT-MOKHTARI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:66 N PAULINE ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-5105
Mailing Address - Country:US
Mailing Address - Phone:901-448-1480
Mailing Address - Fax:901-448-8015
Practice Address - Street 1:1910 NONCONNAH BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38132-2113
Practice Address - Country:US
Practice Address - Phone:901-448-2300
Practice Address - Fax:901-448-6657
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN27884207L00000X
MS18474207LA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3836655Medicaid
TN3836655Medicaid