Provider Demographics
NPI:1942303367
Name:BAKHTAVAR, MOHAMMAD ALI (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD ALI
Middle Name:
Last Name:BAKHTAVAR
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 1:205 NORTH FIRST STR
Mailing Address - Street 2:SUITE D
Mailing Address - City:BLYTHE
Mailing Address - State:CA
Mailing Address - Zip Code:92225
Mailing Address - Country:US
Mailing Address - Phone:760-922-6667
Mailing Address - Fax:760-922-6668
Practice Address - Street 1:205 NORTH FIRST STR
Practice Address - Street 2:SUITE D
Practice Address - City:BLYTHE
Practice Address - State:CA
Practice Address - Zip Code:92225
Practice Address - Country:US
Practice Address - Phone:760-922-6667
Practice Address - Fax:760-922-6668
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC521640207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C521640Medicaid
H32279Medicare UPIN