Provider Demographics
NPI:1790027183
Name:MOGHADAM, BAHRAM TROY (DPM)
Entity Type:Individual
Prefix:
First Name:BAHRAM TROY
Middle Name:
Last Name:MOGHADAM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:TROY
Other - Middle Name:
Other - Last Name:MOGHADAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:760-704-5750
Mailing Address - Fax:
Practice Address - Street 1:2205 VISTA WAY # 210
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-5661
Practice Address - Country:US
Practice Address - Phone:760-704-5750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-23
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE5237213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery