Provider Demographics
NPI:1518960616
Name:FERDOWS, MEHDI S (MD, PHD)
Entity Type:Individual
Prefix:
First Name:MEHDI
Middle Name:S
Last Name:FERDOWS
Suffix:
Gender:M
Credentials:MD, PHD
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 5894
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98668-5894
Mailing Address - Country:US
Mailing Address - Phone:360-823-0880
Mailing Address - Fax:360-823-0883
Practice Address - Street 1:814 NE 87TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-1915
Practice Address - Country:US
Practice Address - Phone:360-823-0880
Practice Address - Fax:360-823-0883
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2012-06-26
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
WAMD000411174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1120799Medicaid
WAF88781Medicare UPIN
WA1120799Medicaid