Provider Demographics
NPI:1932114733
Name:MOGHADAM, MOJTABA I (MD)
Entity Type:Individual
Prefix:
First Name:MOJTABA
Middle Name:
Last Name:MOGHADAM
Suffix:I
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 1:1335 CYPRESS STREET
Mailing Address - Street 2:SUITE # 205
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773
Mailing Address - Country:US
Mailing Address - Phone:909-542-2770
Mailing Address - Fax:909-394-1800
Practice Address - Street 1:1335 W CYPRESS AVE
Practice Address - Street 2:SUITE # 205
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3537
Practice Address - Country:US
Practice Address - Phone:909-542-2770
Practice Address - Fax:909-394-1800
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45294207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty