Healthcare Provider Details

I. General information

NPI: 1225138423
Provider Name (Legal Business Name): SUSAN MOKHTARI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN BAYAT-MOKHTARI MD

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/15/2022
Certification Date: 10/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 NONCONNAH BLVD SUITE 120
MEMPHIS TN
38132-2113
US

IV. Provider business mailing address

66 N PAULINE ST SUITE 206
MEMPHIS TN
38105-5105
US

V. Phone/Fax

Practice location:
  • Phone: 901-448-2300
  • Fax: 901-448-6657
Mailing address:
  • Phone: 901-448-1480
  • Fax: 901-448-8015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number27884
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207LA0401X
TaxonomyAddiction Medicine (Anesthesiology) Physician
License Number18474
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: