Provider Demographics
NPI:1790257970
Name:MAHMOODJANLOO, BEHROOZ
Entity Type:Individual
Prefix:
First Name:BEHROOZ
Middle Name:
Last Name:MAHMOODJANLOO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1713 W 33RD ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-3839
Mailing Address - Country:US
Mailing Address - Phone:405-826-9255
Mailing Address - Fax:
Practice Address - Street 1:1713 W 33RD ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3839
Practice Address - Country:US
Practice Address - Phone:405-826-9255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-27
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK743689122Medicaid