MEDICARE: DR. MINA R MOKHTARI M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	35041223	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	000000117449	OTHER	OH	ANTHEM BLUE CROSS/BLUE SH

General Provider Information

NPI Number	:	1942307731
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MINA R MOKHTARI M.D.

Provider Business Mailing Address
First Line	:	3121 W BROAD ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43204-1306
Country	:	US
Telephone Number	:	614-274-6100
Fax Number	:	614-351-1125

Provider Business Practice Location Address
First Line	:	3121 W BROAD ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43204-1306
Country	:	US
Telephone Number	:	614-274-6100
Fax Number	:	614-351-1125

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	07/13/2007

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