Healthcare Provider Details

I. General information

NPI: 1497508642
Provider Name (Legal Business Name): ALIREZA MAHMOUDI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2024
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 W 76TH ST STE 300
EDINA MN
55435-3004
US

IV. Provider business mailing address

3601 W 76TH ST STE 300
EDINA MN
55435-3004
US

V. Phone/Fax

Practice location:
  • Phone: 952-929-1131
  • Fax:
Mailing address:
  • Phone: 952-929-1131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number39157
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number80140
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: