Provider Demographics
NPI:1265487581
Name:MOATTARI, ALI REZA (MD)
Entity Type:Individual
Prefix:DR
First Name:ALI
Middle Name:REZA
Last Name:MOATTARI
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 1:1441 AVOCADO AVE
Mailing Address - Street 2:SUITE 807
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7721
Mailing Address - Country:US
Mailing Address - Phone:949-706-7706
Mailing Address - Fax:
Practice Address - Street 1:1441 AVOCADO AVE
Practice Address - Street 2:SUITE 807
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7721
Practice Address - Country:US
Practice Address - Phone:949-706-7706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35051579174400000X
CAA46696207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0713008Medicaid
OHA83201Medicare UPIN
OH0713008Medicaid