Provider Demographics
NPI:1770583031
Name:TAHBAZ, MAHYAR (DO)
Entity type:Individual
Prefix:
First Name:MAHYAR
Middle Name:
Last Name:TAHBAZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 AVERY ST STE 501
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-5192
Mailing Address - Country:US
Mailing Address - Phone:304-422-3904
Mailing Address - Fax:304-485-4466
Practice Address - Street 1:400 MATTHEW ST
Practice Address - Street 2:STE 207
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1644
Practice Address - Country:US
Practice Address - Phone:304-422-6304
Practice Address - Fax:304-485-4466
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2022-08-29
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-07
Provider Licenses
StateLicense IDTaxonomies
OH34007944T207R00000X, 207RN0300X
WV1956207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4093084Medicare PIN
OH4093083Medicare PIN