Provider Demographics
NPI:1881005445
Name:ENTEZARALMAHDI, MAHNAZ (MD)
Entity Type:Individual
Prefix:
First Name:MAHNAZ
Middle Name:
Last Name:ENTEZARALMAHDI
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 1:10565 CIVIC CENTER DR BLDG SUITE165
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3853
Mailing Address - Country:US
Mailing Address - Phone:909-985-2211
Mailing Address - Fax:909-985-2244
Practice Address - Street 1:10565 CIVIC CENTER DR BLDG SUITE165
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3853
Practice Address - Country:US
Practice Address - Phone:909-985-2211
Practice Address - Fax:909-985-2244
Is Sole Proprietor?:No
Enumeration Date:2014-05-16
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX390200000X
CAA1472042084P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program