Healthcare Provider Details

I. General information

NPI: 1710627179
Provider Name (Legal Business Name): KEVIN MORTAZAVI MD, MHS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2022
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 ORLEANS ST
BALTIMORE MD
21287-0010
US

IV. Provider business mailing address

1800 ORLEANS ST
BALTIMORE MD
21287-0010
US

V. Phone/Fax

Practice location:
  • Phone: 951-252-3630
  • Fax:
Mailing address:
  • Phone: 614-293-3570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA206455
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: