Basic Information
| Provider Information | |||||||||
| NPI: | 1205041571 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AKHAVANHEIDARI | ||||||||
| FirstName: | MOHAMMAD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 649 | ||||||||
| Address2: | |||||||||
| City: | FORT DEFIANCE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 865040649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287298132 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | CORNER OF ROUTE N12 AND N7 | ||||||||
| Address2: | |||||||||
| City: | FORT DEFIANCE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287298132 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2007 | ||||||||
| LastUpdateDate: | 10/25/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | A108305 | CA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | ME112102 | FL | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 24783 | WV | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | MD437802 | PA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | MT196167 | PA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 45679 | AZ | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.