Provider Demographics
NPI:1437288925
Name:GOLSHAHI, MOHAMMAD (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:GOLSHAHI
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 1:1500 E KATELLA AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-5008
Mailing Address - Country:US
Mailing Address - Phone:714-639-0585
Mailing Address - Fax:714-639-0681
Practice Address - Street 1:1500 E KATELLA AVE
Practice Address - Street 2:SUITE A
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-5008
Practice Address - Country:US
Practice Address - Phone:714-639-0585
Practice Address - Fax:714-639-0681
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC43015174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA74936Medicare UPIN