Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204E00000X | Oral & Maxillofacial Surgeon | 30021604 | OH |
NPI | 1053375048 |
---|---|
Provider Name | Mohammad R Razavi |
First Address | Independence, OH 44131-2139 |
Second Address | Cleveland, OH 44195-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/04/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2537839 | (05) | OH |