MEDICARE: DR. MITRA MAZAHERI PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY8651	CA

General Provider Information

NPI Number	:	1255417671
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MITRA MAZAHERI PHD

Provider Business Mailing Address
First Line	:	465 WEST FIRST ST.
Second Line	:
City	:	TUSTIN
State	:	CA
Zip	:	92780-3002
Country	:	US
Telephone Number	:	714-577-5406
Fax Number	:	714-577-5450

Provider Business Practice Location Address
First Line	:	465 WEST FIRST ST.
Second Line	:
City	:	TUSTIN
State	:	CA
Zip	:	92780-3002
Country	:	US
Telephone Number	:	714-577-5406
Fax Number	:	714-577-5450

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/27/2006
Last Update Date	:	07/08/2007

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