Provider Demographics
NPI:1326004177
Name:NEZAKATGOO, NOSRATOLLAH (MD)
Entity Type:Individual
Prefix:DR
First Name:NOSRATOLLAH
Middle Name:
Last Name:NEZAKATGOO
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 1:66 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:901-448-7642
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?:Not Answered
Enumeration Date:2006-04-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34128204F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3852714Medicaid
TN3157769OtherBC/BS TN
TN3852715Medicare ID - Type UnspecifiedTN MEDICARE
TNH15781Medicare UPIN