Provider Demographics
NPI:1760416770
Name:IMANDOUST, MOHAMMAD (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:IMANDOUST
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 1:16222 TURTLEBACK RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-2013
Mailing Address - Country:US
Mailing Address - Phone:858-673-4553
Mailing Address - Fax:858-673-4553
Practice Address - Street 1:3762 MISSION TRAIL SUITE F
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530
Practice Address - Country:US
Practice Address - Phone:951-674-5686
Practice Address - Fax:951-674-4707
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50910208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC44234Medicare UPIN