Provider Demographics
NPI:1639172604
Name:MASSOUMI, KAMRAN MOHAJER (MD)
Entity Type:Individual
Prefix:
First Name:KAMRAN
Middle Name:MOHAJER
Last Name:MASSOUMI
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 1:1020 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73644-2831
Mailing Address - Country:US
Mailing Address - Phone:580-225-1555
Mailing Address - Fax:580-225-1558
Practice Address - Street 1:1020 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-2831
Practice Address - Country:US
Practice Address - Phone:580-225-1555
Practice Address - Fax:580-225-1558
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23117207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2386811OtherUNITED HEALTHCARE
TX171274701Medicaid
OK200015260AMedicaid
OK7072482OtherAETNA
OKH89644Medicare UPIN
OK200015260AMedicaid
OKP00047979Medicare PIN