Provider Demographics
NPI:1033140934
Name:MAHDAVI, MAHMOOD (MD)
Entity Type:Individual
Prefix:
First Name:MAHMOOD
Middle Name:
Last Name:MAHDAVI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9850 GENESEE AVE
Mailing Address - Street 2:STE 710
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1224
Mailing Address - Country:US
Mailing Address - Phone:858-458-9955
Mailing Address - Fax:858-452-7848
Practice Address - Street 1:9850 GENESEE AVE
Practice Address - Street 2:STE 710
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1224
Practice Address - Country:US
Practice Address - Phone:858-458-9955
Practice Address - Fax:858-452-7848
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC39780207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13709Medicare ID - Type Unspecified
A37219Medicare UPIN