Provider Demographics
NPI:1689884876
Name:MOGHADAMFALAHI, MANA (MD)
Entity Type:Individual
Prefix:
First Name:MANA
Middle Name:
Last Name:MOGHADAMFALAHI
Suffix:
Gender:F
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:PO BOX 1286
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47151-1286
Mailing Address - Country:US
Mailing Address - Phone:502-456-6211
Mailing Address - Fax:502-456-4440
Practice Address - Street 1:1850 STATE ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4990
Practice Address - Country:US
Practice Address - Phone:812-948-4325
Practice Address - Fax:502-456-4440
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01073646A207ZP0102X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000875489OtherANTHEM
IN201153720AMedicaid
KY50083645OtherPASSPORT
KY7100240630Medicaid
IN201153720AMedicaid