Provider Demographics
NPI:1508936907
Name:AMIRKHAN, MOJGAN MICHELE (MD)
Entity Type:Individual
Prefix:
First Name:MOJGAN
Middle Name:MICHELE
Last Name:AMIRKHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 N TUSTIN AVE
Mailing Address - Street 2:SUITE100
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3838
Mailing Address - Country:US
Mailing Address - Phone:714-667-7922
Mailing Address - Fax:714-667-7027
Practice Address - Street 1:1100 N TUSTIN AVE
Practice Address - Street 2:SUITE F
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3509
Practice Address - Country:US
Practice Address - Phone:714-667-7922
Practice Address - Fax:714-667-7027
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG80416207P00000X
CAG080416207Q00000X
WI61080207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D0940482OtherCLIA
KS200633070AMedicaid
CA00G804160Medicaid
CABA4340597OtherDEA
CA00G804160Medicaid
KS200633070AMedicaid
KSKA1209006Medicare PIN
CAAM541ZMedicare PIN