Provider Demographics
NPI:1790777050
Name:MAHMOOD, FAYYAZ (MD)
Entity Type:Individual
Prefix:DR
First Name:FAYYAZ
Middle Name:
Last Name:MAHMOOD
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 1:24988 SE STARK ST
Mailing Address - Street 2:STE 300
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-8322
Mailing Address - Country:US
Mailing Address - Phone:503-674-5818
Mailing Address - Fax:503-674-6709
Practice Address - Street 1:24988 SE STARK ST
Practice Address - Street 2:STE 300
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-8322
Practice Address - Country:US
Practice Address - Phone:503-674-5818
Practice Address - Fax:503-674-6709
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD16510207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR010020Medicaid
OR010020Medicaid
E57942Medicare UPIN