Provider Demographics
NPI:1720010234
Name:MOGHADDAM, MOHSEN TANBAKOOCHI (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHSEN
Middle Name:TANBAKOOCHI
Last Name:MOGHADDAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19100 VENTURA BLVD STE 16
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3234
Mailing Address - Country:US
Mailing Address - Phone:818-609-1314
Mailing Address - Fax:818-609-0841
Practice Address - Street 1:19100 VENTURA BLVD STE 16
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3234
Practice Address - Country:US
Practice Address - Phone:818-609-1314
Practice Address - Fax:818-609-0841
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA46373208D00000X, 207Y00000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A463732Medicaid
CAE60827Medicare UPIN
CA00A463732Medicaid