Provider Demographics
NPI:1518229806
Name:MARIAM MOGHADAM, M.D., INC.
Entity Type:Organization
Organization Name:MARIAM MOGHADAM, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIAM
Authorized Official - Middle Name:SUSAN
Authorized Official - Last Name:MOGHADAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-769-2222
Mailing Address - Street 1:P.O. BOX 8307
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92375-1507
Mailing Address - Country:US
Mailing Address - Phone:951-769-2222
Mailing Address - Fax:951-769-2204
Practice Address - Street 1:81 HIGHLAND SPRINGS AVE.
Practice Address - Street 2:SUITE #306
Practice Address - City:BEAUMONT
Practice Address - State:CA
Practice Address - Zip Code:92223-3170
Practice Address - Country:US
Practice Address - Phone:951-769-2222
Practice Address - Fax:951-769-2204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86456207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABM8774172OtherDEA
CABM8774172OtherDEA