Provider Demographics
NPI:1750384541
Name:RAFIEETARY, MOHAMMAD REZA (OD)
Entity type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:REZA
Last Name:RAFIEETARY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1432 KIMBROUGH RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-2405
Mailing Address - Country:US
Mailing Address - Phone:901-767-4499
Mailing Address - Fax:901-761-0727
Practice Address - Street 1:1432 KIMBROUGH RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-2405
Practice Address - Country:US
Practice Address - Phone:901-767-4499
Practice Address - Fax:901-761-0727
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD1200174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0169638Medicaid
TN3597030Medicare PIN
TNT82572Medicare UPIN