Provider Demographics
NPI:1558354522
Name:MTH CLINIC PC
Entity Type:Organization
Organization Name:MTH CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:FAYYAZ
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHMOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-674-5818
Mailing Address - Street 1:24988 SE STARK ST
Mailing Address - Street 2:STE 300
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-8322
Mailing Address - Country:US
Mailing Address - Phone:503-674-5818
Mailing Address - Fax:503-674-6709
Practice Address - Street 1:24988 SE STARK ST
Practice Address - Street 2:STE 300
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-8322
Practice Address - Country:US
Practice Address - Phone:503-674-5818
Practice Address - Fax:503-674-6709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR104629Medicare PIN