Provider Demographics
NPI:1932296340
Name:MAHDAVY, MUSTAFA (MD)
Entity Type:Individual
Prefix:DR
First Name:MUSTAFA
Middle Name:
Last Name:MAHDAVY
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 1:1117 E. DEVONSHIRE AVE. DEPARTMENT OF PATHOLOGY
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543
Mailing Address - Country:US
Mailing Address - Phone:985-789-7994
Mailing Address - Fax:951-765-4829
Practice Address - Street 1:1117 E. DEVONSHIRE AVE. DEPARTMENT OF PATHOLOGY
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543
Practice Address - Country:US
Practice Address - Phone:985-789-7994
Practice Address - Fax:951-765-4829
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA93215207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1074730Medicaid
LAI35697Medicare UPIN
LA4J737Medicare ID - Type UnspecifiedIND MEDICARE