Provider Demographics
NPI:1356684229
Name:POURMORTEZA, MEHDI (DO)
Entity Type:Individual
Prefix:DR
First Name:MEHDI
Middle Name:
Last Name:POURMORTEZA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4000
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-4000
Mailing Address - Country:US
Mailing Address - Phone:423-926-1171
Mailing Address - Fax:
Practice Address - Street 1:809 LAMONT ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-5453
Practice Address - Country:US
Practice Address - Phone:423-926-1171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-29
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102204343207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine