Healthcare Provider Details

I. General information

NPI: 1790777050
Provider Name (Legal Business Name): FAYYAZ MAHMOOD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 11/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24988 SE STARK ST STE 300
GRESHAM OR
97030-8322
US

IV. Provider business mailing address

24988 SE STARK ST STE 300
GRESHAM OR
97030-8322
US

V. Phone/Fax

Practice location:
  • Phone: 503-674-5818
  • Fax: 503-674-6709
Mailing address:
  • Phone: 503-674-5818
  • Fax: 503-674-6709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD16510
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: