Provider Demographics
NPI:1689782708
Name:MORTAZAVI, FARIBORZ (MD)
Entity Type:Individual
Prefix:
First Name:FARIBORZ
Middle Name:
Last Name:MORTAZAVI
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 1:1700 N ROSE AVE
Mailing Address - Street 2:SUITE 320
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93030-7648
Mailing Address - Country:US
Mailing Address - Phone:805-485-8709
Mailing Address - Fax:805-485-5521
Practice Address - Street 1:1700 N ROSE AVE SUITE 320
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-7648
Practice Address - Country:US
Practice Address - Phone:805-485-8709
Practice Address - Fax:805-485-5521
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-107982207RH0003X
CAA96026207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB255229Medicare PIN