Basic Information
| Provider Information | |||||||||
| NPI: | 1457616914 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MORTAZIE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | BABAK | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2285 CORPORATE CIR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890747759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023602763 | ||||||||
| FaxNumber: | 9497832880 | ||||||||
| Practice Location | |||||||||
| Address1: | 1506 E CHAPMAN AVE | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928662231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145388556 | ||||||||
| FaxNumber: | 7145381082 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2012 | ||||||||
| LastUpdateDate: | 09/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0101X | 14600 | CA | Y | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery |
No ID Information.