Healthcare Provider Details

I. General information

NPI: 1679079115
Provider Name (Legal Business Name): FATEMEH MIRZAMOHAMMADI MD,PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 SOUTHERN BLVD STE 201
KETTERING OH
45429-1265
US

IV. Provider business mailing address

3700 SOUTHERN BLVD STE 201
KETTERING OH
45429-1265
US

V. Phone/Fax

Practice location:
  • Phone: 855-500-2873
  • Fax:
Mailing address:
  • Phone: 855-500-2873
  • Fax: 937-281-3805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number35.156456
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number1022749
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: