Provider Demographics
NPI:1952372419
Name:MAZLOOMDOOST, CAMELLIA (MD)
Entity Type:Individual
Prefix:MRS
First Name:CAMELLIA
Middle Name:
Last Name:MAZLOOMDOOST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:CAMELLIA
Other - Middle Name:SHIRAZI
Other - Last Name:MAZLOOMDOOST
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:715 SHAKER DR
Mailing Address - Street 2:STE 101 PAIN MANAGEMENT MEDICINE
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504
Mailing Address - Country:US
Mailing Address - Phone:859-275-4878
Mailing Address - Fax:859-276-5400
Practice Address - Street 1:715 SHAKER DR
Practice Address - Street 2:STE 101 PAIN MANAGEMENT MEDICINE
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504
Practice Address - Country:US
Practice Address - Phone:859-275-4878
Practice Address - Fax:859-276-5400
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY256852084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64256852Medicaid
KY000000049975OtherBLUE CROSS BLUE SHIELD
KY1547202Medicare ID - Type Unspecified
F47669Medicare UPIN
KY000000049975OtherBLUE CROSS BLUE SHIELD