Provider Demographics
NPI:1417193087
Name:POOSTIZADEH, MOHAMMAD JAVAD (MD)
Entity Type:Individual
Prefix:MR
First Name:MOHAMMAD
Middle Name:JAVAD
Last Name:POOSTIZADEH
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 1:1900 44TH ST SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:245 CHERRY ST SE
Practice Address - Street 2:STE 104
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-685-8620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-01
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI43011040312084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program