Provider Demographics
NPI:1457616914
Name:MORTAZIE, MICHAEL BABAK (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BABAK
Last Name:MORTAZIE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2285 CORPORATE CIR
Mailing Address - Street 2:STE 200
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-7759
Mailing Address - Country:US
Mailing Address - Phone:702-360-2763
Mailing Address - Fax:949-783-2880
Practice Address - Street 1:1506 E CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-2231
Practice Address - Country:US
Practice Address - Phone:714-538-8556
Practice Address - Fax:714-538-1082
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2020-09-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA14600207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery