Provider Demographics
NPI:1366012627
Name:BEIRAGHDAR, MITRA (DC)
Entity Type:Individual
Prefix:
First Name:MITRA
Middle Name:
Last Name:BEIRAGHDAR
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14770 MEMORIAL DR STE 220
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77079-5252
Mailing Address - Country:US
Mailing Address - Phone:281-977-8372
Mailing Address - Fax:
Practice Address - Street 1:12188 GULF FWY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77034-4442
Practice Address - Country:US
Practice Address - Phone:281-977-8384
Practice Address - Fax:713-636-2559
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14695111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX14695OtherTEXAS BOARD OF CHIROPRACTIC EXAMINERS