Provider Demographics
NPI:1376625426
Name:MOGHADDAS, NIMA (DPM)
Entity Type:Individual
Prefix:
First Name:NIMA
Middle Name:
Last Name:MOGHADDAS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 PALMER ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CALAIS
Mailing Address - State:ME
Mailing Address - Zip Code:04619-1305
Mailing Address - Country:US
Mailing Address - Phone:207-454-8195
Mailing Address - Fax:207-454-3840
Practice Address - Street 1:37 PALMER ST
Practice Address - Street 2:SUITE 3
Practice Address - City:CALAIS
Practice Address - State:ME
Practice Address - Zip Code:04619-1305
Practice Address - Country:US
Practice Address - Phone:207-454-8195
Practice Address - Fax:207-454-3840
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPOD1001213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME235700099Medicaid
MEPOD1001OtherSTATE LICENSE
ME235700099Medicaid
MEPOD1001OtherSTATE LICENSE
U52272Medicare UPIN