Provider Demographics
NPI:1841449535
Name:MOHROKH HEDAYATI, MD
Entity type:Organization
Organization Name:MOHROKH HEDAYATI, MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ABBY
Authorized Official - Middle Name:F
Authorized Official - Last Name:HENISEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-306-4456
Mailing Address - Street 1:3142 HORIZON RD STE 200
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032-7814
Mailing Address - Country:US
Mailing Address - Phone:214-306-4456
Mailing Address - Fax:214-306-4457
Practice Address - Street 1:3142 HORIZON RD STE 200
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-7814
Practice Address - Country:US
Practice Address - Phone:214-306-4456
Practice Address - Fax:214-306-4457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-17
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX409816201Medicaid
TX035948107Medicaid