Provider Demographics
NPI:1407067614
Name:YASREBI, MEHRDAD
Entity Type:Individual
Prefix:DR
First Name:MEHRDAD
Middle Name:
Last Name:YASREBI
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:MIKE
Other - Middle Name:
Other - Last Name:YAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:PO BOX 862
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-0862
Mailing Address - Country:US
Mailing Address - Phone:503-380-5646
Mailing Address - Fax:
Practice Address - Street 1:1390 SE 122ND AVE
Practice Address - Street 2:SUITE LW1
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1203
Practice Address - Country:US
Practice Address - Phone:503-256-1557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11922174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist