Provider Demographics
NPI:1578687521
Name:TAVASSOLI, MOHAMMAD (DO)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:TAVASSOLI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3230 RUE CHANEL APT 158
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-6669
Mailing Address - Country:US
Mailing Address - Phone:317-717-1894
Mailing Address - Fax:
Practice Address - Street 1:4902 E THOMPSON RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-1905
Practice Address - Country:US
Practice Address - Phone:317-786-1888
Practice Address - Fax:317-786-1889
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002291A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine