Provider Demographics
NPI:1609863091
Name:MOUSSAVIAN-ASSADI, MINA (MD)
Entity Type:Individual
Prefix:DR
First Name:MINA
Middle Name:
Last Name:MOUSSAVIAN-ASSADI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MINA
Other - Middle Name:
Other - Last Name:MOUSSAVIAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 9602
Mailing Address - Street 2:
Mailing Address - City:MISSION HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91346-9602
Mailing Address - Country:US
Mailing Address - Phone:818-837-5559
Mailing Address - Fax:818-792-4793
Practice Address - Street 1:5525 ETIWANDA AVE
Practice Address - Street 2:#212
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3647
Practice Address - Country:US
Practice Address - Phone:818-721-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216492208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2001110Medicaid
MA2001110Medicaid