Healthcare Provider Details

I. General information

NPI: 1942307731
Provider Name (Legal Business Name): MINA R MOKHTARI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3121 W BROAD ST
COLUMBUS OH
43204-1306
US

IV. Provider business mailing address

3121 W BROAD ST
COLUMBUS OH
43204-1306
US

V. Phone/Fax

Practice location:
  • Phone: 614-274-6100
  • Fax: 614-351-1125
Mailing address:
  • Phone: 614-274-6100
  • Fax: 614-351-1125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35041223
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: