Provider Demographics
NPI:1346218658
Name:MAKHSOOSI, MOJGAN (MD INC)
Entity Type:Individual
Prefix:
First Name:MOJGAN
Middle Name:
Last Name:MAKHSOOSI
Suffix:
Gender:F
Credentials:MD INC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6604
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91359-6604
Mailing Address - Country:US
Mailing Address - Phone:805-915-0315
Mailing Address - Fax:
Practice Address - Street 1:2750 SYCAMORE DR STE 209
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1500
Practice Address - Country:US
Practice Address - Phone:805-915-0315
Practice Address - Fax:805-915-0317
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-10
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70736207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG94619Medicare UPIN