Provider Demographics
NPI:1811002918
Name:RAHMANIZADEH, MAHASTI (MD)
Entity Type:Individual
Prefix:DR
First Name:MAHASTI
Middle Name:
Last Name:RAHMANIZADEH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 N PERRY ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342-2217
Mailing Address - Country:US
Mailing Address - Phone:248-338-5516
Mailing Address - Fax:248-338-5547
Practice Address - Street 1:385 N LAPEER RD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MI
Practice Address - Zip Code:48371-3610
Practice Address - Country:US
Practice Address - Phone:248-628-3000
Practice Address - Fax:248-628-2781
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301084150208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4701111-10Medicaid
MI4701111-10Medicaid
F36228174Medicare ID - Type Unspecified