Provider Demographics
NPI:1609863802
Name:MORTAZAVI, ALI (DO)
Entity Type:Individual
Prefix:DR
First Name:ALI
Middle Name:
Last Name:MORTAZAVI
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 1:2041 MESA VALLEY WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-8157
Mailing Address - Country:US
Mailing Address - Phone:770-944-1100
Mailing Address - Fax:770-944-6469
Practice Address - Street 1:2041 MESA VALLEY WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-8157
Practice Address - Country:US
Practice Address - Phone:770-944-1100
Practice Address - Fax:770-944-6469
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054865207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA234083867BMedicaid
GA234083867EMedicaid
GA234083867CMedicaid
GA234083867AMedicaid
GA234083867BMedicaid
GA234083867AMedicaid