Provider Demographics
NPI:1508965476
Name:AMADPOUR, MOE (MD)
Entity Type:Individual
Prefix:DR
First Name:MOE
Middle Name:
Last Name:AMADPOUR
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 1:1159 ROADRUNNER WAY
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-3159
Mailing Address - Country:US
Mailing Address - Phone:805-583-2643
Mailing Address - Fax:805-583-0111
Practice Address - Street 1:1159 ROADRUNNER WAY
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-3159
Practice Address - Country:US
Practice Address - Phone:805-583-2643
Practice Address - Fax:805-583-0111
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG81182207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G811820Medicaid
CA95-4761541OtherINDIVIDUAL TAX ID#
CAG81182OtherMEDICAL STATE LIC#
CAG81182CMedicare ID - Type UnspecifiedMEDICARE ID#
CA00G811820Medicaid
CAP00308901Medicare ID - Type UnspecifiedRAILROAD MCARE ID#