Provider Demographics
NPI:1184795809
Name:YAZDANBAKHSH, NIKOU (MD)
Entity type:Individual
Prefix:
First Name:NIKOU
Middle Name:
Last Name:YAZDANBAKHSH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MINA
Other - Middle Name:N
Other - Last Name:YAZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 24812
Mailing Address - Street 2:4501 POWELL RD
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2611 WAYNE AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45420
Practice Address - Country:US
Practice Address - Phone:937-258-0440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35100308103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist