Provider Demographics
NPI:1275700478
Name:MOGHADDAM, SAMER (MD)
Entity Type:Individual
Prefix:
First Name:SAMER
Middle Name:
Last Name:MOGHADDAM
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 1:17595 HARVARD AVE STE C146
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-8516
Mailing Address - Country:US
Mailing Address - Phone:657-212-5177
Mailing Address - Fax:
Practice Address - Street 1:902 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4218
Practice Address - Country:US
Practice Address - Phone:909-558-4475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA121187207RP1001X
CAA122187207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease