Provider Demographics
NPI:1194898064
Name:RAISZADEH, MAHINDOKHT MARY (MD)
Entity type:Individual
Prefix:DR
First Name:MAHINDOKHT
Middle Name:MARY
Last Name:RAISZADEH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5222 BALBOA AVE
Mailing Address - Street 2:STE 45
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-6904
Mailing Address - Country:US
Mailing Address - Phone:858-616-6430
Mailing Address - Fax:
Practice Address - Street 1:5222 BALBOA AVE
Practice Address - Street 2:STE 45
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-6904
Practice Address - Country:US
Practice Address - Phone:858-616-6430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34656173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A346561Medicaid
CAA34656Medicare ID - Type UnspecifiedLICENSE