Provider Demographics
NPI:1205082898
Name:MORTEZA MONTAZERI,M.D.INC
Entity type:Organization
Organization Name:MORTEZA MONTAZERI,M.D.INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MORTEZA
Authorized Official - Middle Name:N
Authorized Official - Last Name:MONTAZERI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-357-6700
Mailing Address - Street 1:910 SW 38TH ST
Mailing Address - Street 2:SUITE#A
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-7013
Mailing Address - Country:US
Mailing Address - Phone:580-357-6700
Mailing Address - Fax:580-357-9912
Practice Address - Street 1:910 SW 38TH ST
Practice Address - Street 2:SUITE#A
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-7013
Practice Address - Country:US
Practice Address - Phone:580-357-6700
Practice Address - Fax:580-357-9912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-14
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13452174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOKB5160Medicare PIN