Healthcare Provider Details

I. General information

NPI: 1225299647
Provider Name (Legal Business Name): ALI MOKHTARZADEH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2008
Last Update Date: 07/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 DELAWARE ST SE MMC 493
MINNEAPOLIS MN
55455-0341
US

IV. Provider business mailing address

420 DELAWARE ST SE MMC 493
MINNEAPOLIS MN
55455-0341
US

V. Phone/Fax

Practice location:
  • Phone: 612-625-4654
  • Fax: 612-626-3119
Mailing address:
  • Phone: 612-625-4654
  • Fax: 612-626-3119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number55387
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License Number55387
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: