Healthcare Provider Details

I. General information

NPI: 1184795809
Provider Name (Legal Business Name): NIKOU YAZDANBAKHSH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MINA N YAZ MD

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2611 WAYNE AVE
DAYTON OH
45420
US

IV. Provider business mailing address

PO BOX 24812 4501 POWELL RD
DAYTON OH
45424
US

V. Phone/Fax

Practice location:
  • Phone: 937-258-0440
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number35100308
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: