Provider Demographics
NPI:1689625634
Name:TAVALLAEE, MEHRDAD (MD)
Entity Type:Individual
Prefix:DR
First Name:MEHRDAD
Middle Name:
Last Name:TAVALLAEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MEHRDAD
Other - Middle Name:M
Other - Last Name:TAVALLAEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2021 BANEY RD S STE A
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44805-4574
Mailing Address - Country:US
Mailing Address - Phone:419-289-1133
Mailing Address - Fax:419-289-1132
Practice Address - Street 1:2021 BANEY RD S STE A
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OH
Practice Address - Zip Code:44805-4574
Practice Address - Country:US
Practice Address - Phone:419-289-1133
Practice Address - Fax:419-289-1132
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35079062T207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2247429Medicaid
OHTA4052412Medicare PIN
OHP00390925Medicare PIN
OHH38720Medicare UPIN