Provider Demographics
NPI:1740591650
Name:MOSTOFA, KEKA AMIN (MD)
Entity Type:Individual
Prefix:
First Name:KEKA
Middle Name:AMIN
Last Name:MOSTOFA
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 1:3400 DATA DR
Mailing Address - Street 2:PHYSICIAN SUPPORT SERVICES
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:916-379-2948
Mailing Address - Fax:916-858-7065
Practice Address - Street 1:1650 CREEKSIDE DR
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3400
Practice Address - Country:US
Practice Address - Phone:916-986-4426
Practice Address - Fax:916-986-4434
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-24
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC186191390200000X
CAA125471207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program