Provider Demographics
NPI:1235621590
Name:MOGHADAM, NIMA M (MD)
Entity Type:Individual
Prefix:
First Name:NIMA
Middle Name:M
Last Name:MOGHADAM
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 1:3701 SKYPARK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4712
Mailing Address - Country:US
Mailing Address - Phone:310-378-2234
Mailing Address - Fax:
Practice Address - Street 1:3701 SKYPARK DR STE 100
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4712
Practice Address - Country:US
Practice Address - Phone:310-378-2234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-03
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA174158207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program