Provider Demographics
NPI:1225235237
Name:MOHTASHAM, LIDA (MD)
Entity Type:Individual
Prefix:
First Name:LIDA
Middle Name:
Last Name:MOHTASHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 E PENN SQ
Mailing Address - Street 2:9TH FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-3323
Mailing Address - Country:US
Mailing Address - Phone:267-425-9258
Mailing Address - Fax:267-425-9299
Practice Address - Street 1:3401 CIVIC CENTER BLVD
Practice Address - Street 2:CHILDREN'S HOSPITAL OF PHILADELPHIA - PULMONOLOGY
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4319
Practice Address - Country:US
Practice Address - Phone:215-590-3749
Practice Address - Fax:215-590-3500
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD434388208000000X, 2080P0214X
PAMT2053872080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics