Basic Information
| Provider Information | |||||||||
| NPI: | 1659403426 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALI MOKHTARI, MD, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3121 W BROAD ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432041306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143510450 | ||||||||
| FaxNumber: | 6143511125 | ||||||||
| Practice Location | |||||||||
| Address1: | 3121 W BROAD ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432041306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143510450 | ||||||||
| FaxNumber: | 6143511125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 06/13/2008 | ||||||||
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| AuthorizedOfficialLastName: | MOKHTARI | ||||||||
| AuthorizedOfficialFirstName: | ALI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6143510450 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 35035614 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0226197 | 05 | OH | MEDICAID |