Provider Demographics
NPI:1679509111
Name:MIRTORABI, MEHDI M (MD)
Entity Type:Individual
Prefix:
First Name:MEHDI
Middle Name:M
Last Name:MIRTORABI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SEID MEHDI
Other - Middle Name:
Other - Last Name:MIRTORABI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2155 NW 173RD AVE
Mailing Address - Street 2:SUITE 102
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
Practice Address - Street 2:SUITE 102
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-25
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22580207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
131910Medicare PIN
H24687Medicare UPIN