Provider Demographics
NPI:1235488420
Name:MAHMOODJANLOO, REZA
Entity Type:Individual
Prefix:
First Name:REZA
Middle Name:
Last Name:MAHMOODJANLOO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4715 INNSBROOK LN
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73142-5111
Mailing Address - Country:US
Mailing Address - Phone:405-413-4979
Mailing Address - Fax:
Practice Address - Street 1:4436 NW 50TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2212
Practice Address - Country:US
Practice Address - Phone:405-858-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-04
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker