Provider Demographics
NPI:1891887287
Name:MOTAMEDI, FARHAD (MD)
Entity Type:Individual
Prefix:DR
First Name:FARHAD
Middle Name:
Last Name:MOTAMEDI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MOTAMEDI-
Other - Middle Name:MODARRESI A
Other - Last Name:PROFFESIONAL CORPORATION
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3519
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90408-3519
Mailing Address - Country:US
Mailing Address - Phone:310-575-9995
Mailing Address - Fax:310-575-6665
Practice Address - Street 1:11600 WILSHIRE BLVD
Practice Address - Street 2:SUITE 508
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-5781
Practice Address - Country:US
Practice Address - Phone:310-575-9995
Practice Address - Fax:310-575-6665
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39018208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A390181Medicaid
CA00A390181Medicaid
CA0860160001Medicare NSC
CAA39018Medicare PIN