Provider Demographics
NPI:1649054289
Name:MIRZAZADEH JAVAHERI, MASOUD RAMIN
Entity type:Individual
Prefix:
First Name:MASOUD RAMIN
Middle Name:
Last Name:MIRZAZADEH JAVAHERI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 NANSEN SMT
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-1066
Mailing Address - Country:US
Mailing Address - Phone:503-217-9767
Mailing Address - Fax:
Practice Address - Street 1:8029 SE WOODSTOCK BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-5885
Practice Address - Country:US
Practice Address - Phone:503-774-1776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6313111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor