Provider Demographics
NPI:1710095419
Name:MAHJOURI, FEREYDOON (MD)
Entity Type:Individual
Prefix:DR
First Name:FEREYDOON
Middle Name:
Last Name:MAHJOURI
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 1:500 OSBORNE RD NE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-2765
Mailing Address - Country:US
Mailing Address - Phone:763-780-2770
Mailing Address - Fax:763-780-2812
Practice Address - Street 1:500 OSBORNE RD NE
Practice Address - Street 2:SUITE 130
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-2765
Practice Address - Country:US
Practice Address - Phone:763-780-2770
Practice Address - Fax:763-780-2812
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN23415174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA94506Medicare UPIN