Provider Demographics
NPI:1477920692
Name:MOVAFAGH (MOVA), FAZLOLLH(FRED) SR (M D)
Entity Type:Individual
Prefix:DR
First Name:FAZLOLLH(FRED)
Middle Name:
Last Name:MOVAFAGH (MOVA)
Suffix:SR
Gender:M
Credentials:M D
Other - Prefix:DR
Other - First Name:FRED
Other - Middle Name:FAZLOLLAH
Other - Last Name:MOVA
Other - Suffix:SR
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1231 CABRILLO AVE. #201A
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501
Mailing Address - Country:US
Mailing Address - Phone:877-818-1011
Mailing Address - Fax:
Practice Address - Street 1:1231 CABRILLO AVE # 201A
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90501-2867
Practice Address - Country:US
Practice Address - Phone:877-818-1011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA36079208200000X, 261QC1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate Health