Provider Demographics
NPI:1124265285
Name:MORTAZAVI, KAYVAAN M (MD)
Entity type:Individual
Prefix:
First Name:KAYVAAN
Middle Name:M
Last Name:MORTAZAVI
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5055 E BROADWAY BLVD STE A100
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-3629
Mailing Address - Country:US
Mailing Address - Phone:520-327-0460
Mailing Address - Fax:
Practice Address - Street 1:6236 E PIMA ST STE 100
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-3164
Practice Address - Country:US
Practice Address - Phone:520-327-6874
Practice Address - Fax:520-327-0028
Is Sole Proprietor?:No
Enumeration Date:2009-01-12
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ42417207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ524573Medicaid
AZZ138114Medicare PIN
AZ524573Medicaid