Provider Demographics
NPI:1689852022
Name:MOGHADDAS, BAHMAN
Entity Type:Individual
Prefix:MR
First Name:BAHMAN
Middle Name:
Last Name:MOGHADDAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 BALBOA BLVD STE G
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-4578
Mailing Address - Country:US
Mailing Address - Phone:818-902-1919
Mailing Address - Fax:818-902-0505
Practice Address - Street 1:6800 BALBOA BLVD STE G
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-4578
Practice Address - Country:US
Practice Address - Phone:818-902-1919
Practice Address - Fax:818-902-0505
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-07
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASL5568156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician