Provider Demographics
NPI:1942430806
Name:MOOSSAZADEH, DAVID (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:MOOSSAZADEH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11540 SANTA MONICA BLVD SUITE 204
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025
Mailing Address - Country:US
Mailing Address - Phone:888-774-3254
Mailing Address - Fax:
Practice Address - Street 1:11540 SANTA MONICA BLVD SUITE 204
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025
Practice Address - Country:US
Practice Address - Phone:888-774-3254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-24
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11456207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine