Provider Demographics
NPI:1164587713
Name:MOVAFAGH, ALI MOHAMMAD (MD)
Entity Type:Individual
Prefix:MR
First Name:ALI
Middle Name:MOHAMMAD
Last Name:MOVAFAGH
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 1:12712 HEACOCK ST
Mailing Address - Street 2:STE 1
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553
Mailing Address - Country:US
Mailing Address - Phone:951-485-0335
Mailing Address - Fax:951-485-1514
Practice Address - Street 1:12712 HEACOCK ST
Practice Address - Street 2:STE 1
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553
Practice Address - Country:US
Practice Address - Phone:951-485-0335
Practice Address - Fax:951-485-1514
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC42507207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C425070Medicaid
E25153Medicare UPIN