Provider Demographics
NPI:1982197901
Name:MOSHTAGH SISAN, MAHTAB (MD)
Entity Type:Individual
Prefix:
First Name:MAHTAB
Middle Name:
Last Name:MOSHTAGH SISAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-301-8707
Mailing Address - Fax:310-301-8751
Practice Address - Street 1:19950 RINALDI ST STE 300
Practice Address - Street 2:
Practice Address - City:PORTER RANCH
Practice Address - State:CA
Practice Address - Zip Code:91326-4141
Practice Address - Country:US
Practice Address - Phone:818-271-2400
Practice Address - Fax:818-271-2401
Is Sole Proprietor?:No
Enumeration Date:2018-06-13
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA173400207Q00000X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine