Basic Information
| Provider Information | |||||||||
| NPI: | 1225138423 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOKHTARI | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BAYAT-MOKHTARI | ||||||||
| OtherFirstName: | SUSAN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 66 N PAULINE ST | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381055105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014481480 | ||||||||
| FaxNumber: | 9014488015 | ||||||||
| Practice Location | |||||||||
| Address1: | 1910 NONCONNAH BLVD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381322113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014482300 | ||||||||
| FaxNumber: | 9014486657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 07/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 27884 | TN | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LA0401X | 18474 | MS | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3836655 | 05 | TN | MEDICAID |