Provider Demographics
NPI:1326247404
Name:MOSHFEGH, MOUSSA (MD)
Entity Type:Individual
Prefix:DR
First Name:MOUSSA
Middle Name:
Last Name:MOSHFEGH
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 1:6221 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 404
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5201
Mailing Address - Country:US
Mailing Address - Phone:323-933-3810
Mailing Address - Fax:323-933-7522
Practice Address - Street 1:6221 WILSHIRE BLVD
Practice Address - Street 2:SUITE 404
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5201
Practice Address - Country:US
Practice Address - Phone:323-933-3810
Practice Address - Fax:323-933-7522
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38055208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A380550Medicaid
CAA28523Medicare PIN
CA00A380550Medicaid