Provider Demographics
NPI:1659461358
Name:MOMTAZBAKHSH, SASSAN (MD)
Entity Type:Individual
Prefix:
First Name:SASSAN
Middle Name:
Last Name:MOMTAZBAKHSH
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:PO BOX 43130
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85733-3130
Mailing Address - Country:US
Mailing Address - Phone:520-722-3777
Mailing Address - Fax:520-296-6224
Practice Address - Street 1:7383 E TANQUE VERDE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-3475
Practice Address - Country:US
Practice Address - Phone:520-318-3434
Practice Address - Fax:520-318-3435
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32163207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ877392Medicaid
AZI06730Medicare UPIN
AZZ106166Medicare PIN