Provider Demographics
NPI:1104842327
Name:NOURI-MOGHADDAM, SORAYA (MD)
Entity Type:Individual
Prefix:DR
First Name:SORAYA
Middle Name:
Last Name:NOURI-MOGHADDAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CHILDRENS PL
Mailing Address - Street 2:C B 8116
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1002
Mailing Address - Country:US
Mailing Address - Phone:314-454-6095
Mailing Address - Fax:314-454-4801
Practice Address - Street 1:1 CHILDRENS PL
Practice Address - Street 2:SUITE 5S30
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1002
Practice Address - Country:US
Practice Address - Phone:314-454-6095
Practice Address - Fax:314-454-4801
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR82382080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9170765004Medicaid
MO200889129Medicaid
MO200889129Medicaid
P00012615Medicare PIN
IL9170765004Medicaid