Provider Demographics
NPI:1801847694
Name:TAVAKOLI, MOJGAN (DPM)
Entity Type:Individual
Prefix:
First Name:MOJGAN
Middle Name:
Last Name:TAVAKOLI
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4461 COIT RD
Mailing Address - Street 2:SUITE 409
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-0526
Mailing Address - Country:US
Mailing Address - Phone:972-712-7773
Mailing Address - Fax:972-712-3134
Practice Address - Street 1:4461 COIT RD
Practice Address - Street 2:SUITE 409
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75035-0526
Practice Address - Country:US
Practice Address - Phone:972-712-7773
Practice Address - Fax:972-712-3134
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1549213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8B8721OtherBLUE CROSS BLUE SHIELD
TX148569001Medicaid
TX752946496OtherCOMMERCIAL
TX148568201Medicaid
U85530Medicare UPIN
TX148569001Medicaid