Provider Demographics
NPI:1518062819
Name:MEHRZAD, AZIZULLAH (MD)
Entity Type:Individual
Prefix:
First Name:AZIZULLAH
Middle Name:
Last Name:MEHRZAD
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:PO BOX 23229
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42304-3229
Mailing Address - Country:US
Mailing Address - Phone:270-688-1330
Mailing Address - Fax:270-688-1338
Practice Address - Street 1:1000 BRECKENRIDGE ST STE 401
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-0878
Practice Address - Country:US
Practice Address - Phone:270-688-4401
Practice Address - Fax:270-688-4409
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY57755207RG0300X
IN01057692A207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200446820Medicaid
INP00062195Medicare ID - Type UnspecifiedRR MCARE #
IN200446820Medicaid
IN351860EMedicare ID - Type Unspecified