Provider Demographics
NPI:1851388607
Name:RAZAVI, MAHMOOD KAFAII (MD)
Entity Type:Individual
Prefix:
First Name:MAHMOOD
Middle Name:KAFAII
Last Name:RAZAVI
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 1:1140 W LA VETA AVE STE 850
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4218
Mailing Address - Country:US
Mailing Address - Phone:714-560-4450
Mailing Address - Fax:714-560-4455
Practice Address - Street 1:1140 W LA VETA AVE
Practice Address - Street 2:STE. 850
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4225
Practice Address - Country:US
Practice Address - Phone:714-560-4450
Practice Address - Fax:714-560-4455
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG662742085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G662740OtherBLUE SHIELD OF CA
00G662740 M46OtherCALOPTIMA
CA00G662740Medicaid
P00323560OtherRAILROAD MEDICARE
053304CF82916OtherTRAILBLAZER
00G662740OtherBLUE SHIELD OF CA
WG66274CMedicare PIN