Provider Demographics
NPI:1639353378
Name:MIR CLINIC, P.C.
Entity Type:Organization
Organization Name:MIR CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MEHDI
Authorized Official - Middle Name:M
Authorized Official - Last Name:MIRTORABI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-531-9990
Mailing Address - Street 1:2155 NW 173RD AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-3563
Mailing Address - Country:US
Mailing Address - Phone:503-531-9990
Mailing Address - Fax:503-531-9996
Practice Address - Street 1:2155 NW 173RD AVE STE 102
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-3563
Practice Address - Country:US
Practice Address - Phone:503-531-9990
Practice Address - Fax:503-531-9996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22580207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
131909Medicare PIN