Provider Demographics
NPI:1942307731
Name:MOKHTARI, MINA R (MD)
Entity Type:Individual
Prefix:DR
First Name:MINA
Middle Name:R
Last Name:MOKHTARI
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 1:3121 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-1306
Mailing Address - Country:US
Mailing Address - Phone:614-274-6100
Mailing Address - Fax:614-351-1125
Practice Address - Street 1:3121 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-1306
Practice Address - Country:US
Practice Address - Phone:614-274-6100
Practice Address - Fax:614-351-1125
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35041223207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0359811Medicaid
OH000000117449OtherANTHEM BLUE CROSS/BLUE SH
OHMO0446051Medicare ID - Type Unspecified
OH0359811Medicaid