Provider Demographics
NPI:1336395458
Name:YAZDI, MITRA (MD)
Entity Type:Individual
Prefix:DR
First Name:MITRA
Middle Name:
Last Name:YAZDI
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 1:3400 DATA DR
Mailing Address - Street 2:ATTN: CREDENTIALING/PAYER ENROLLMENT
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2330 W COVELL BLVD
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-5658
Practice Address - Country:US
Practice Address - Phone:530-668-2600
Practice Address - Fax:530-406-2897
Is Sole Proprietor?:No
Enumeration Date:2008-08-08
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11013450A207Q00000X
CAA110552207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine