Provider Demographics
NPI:1457300386
Name:HAMIDREZA MOGHADDAM MD PA
Entity Type:Organization
Organization Name:HAMIDREZA MOGHADDAM MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HAMIDREZA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOGHADDAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-895-9233
Mailing Address - Street 1:527 NE 124TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-5423
Mailing Address - Country:US
Mailing Address - Phone:305-895-9233
Mailing Address - Fax:305-895-9274
Practice Address - Street 1:527 NE 124TH ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33161-5423
Practice Address - Country:US
Practice Address - Phone:305-895-9233
Practice Address - Fax:305-895-9274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91771207R00000X
FLPO3670213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273130400Medicaid
FLI-42429Medicare UPIN
FL273130400Medicaid