Provider Demographics
NPI:1396846952
Name:KHANMOHAMADI, MOLOUD A (MD)
Entity Type:Individual
Prefix:
First Name:MOLOUD
Middle Name:A
Last Name:KHANMOHAMADI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MOLOUD
Other - Middle Name:A
Other - Last Name:ZADEH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:50 UNION AVE
Mailing Address - Street 2:STE 604
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-3292
Mailing Address - Country:US
Mailing Address - Phone:973-375-2246
Mailing Address - Fax:973-375-3157
Practice Address - Street 1:50 UNION AVE
Practice Address - Street 2:STE 604
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-3292
Practice Address - Country:US
Practice Address - Phone:973-375-2246
Practice Address - Fax:973-375-3157
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA33695208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
D06423Medicare UPIN
NJZA444250Medicare ID - Type Unspecified