Provider Demographics
NPI:1619914421
Name:MONTAZERI, MORTEZA (MD)
Entity Type:Individual
Prefix:DR
First Name:MORTEZA
Middle Name:
Last Name:MONTAZERI
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 1:910 SW 38TH ST
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-7013
Mailing Address - Country:US
Mailing Address - Phone:580-357-6700
Mailing Address - Fax:580-357-9912
Practice Address - Street 1:910 SW 38TH ST
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-7013
Practice Address - Country:US
Practice Address - Phone:580-357-6700
Practice Address - Fax:580-357-9912
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13452174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOK70030Medicare PIN