Provider Demographics
NPI:1518056977
Name:MOTAMEDI & MODARRESI A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MOTAMEDI & MODARRESI A PROFESSIONAL CORPORATION
Other - Org Name:FARHAD MOTAMEDI
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FARHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:MOTAMEDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-575-9995
Mailing Address - Street 1:PO BOX 3519
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90408-3519
Mailing Address - Country:US
Mailing Address - Phone:310-575-9995
Mailing Address - Fax:310-575-6665
Practice Address - Street 1:11600 WILSHIRE BLVD
Practice Address - Street 2:SUITE 508
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-5781
Practice Address - Country:US
Practice Address - Phone:316-575-9995
Practice Address - Fax:310-575-6665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39018208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A390181Medicaid
CAA39018Medicare ID - Type Unspecified
CA0860160001Medicare NSC
CA00A390181Medicaid