Provider Demographics
NPI:1023066891
Name:FARR, MORTEZA MOOSAVI (DO)
Entity type:Individual
Prefix:
First Name:MORTEZA
Middle Name:MOOSAVI
Last Name:FARR
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 1:125 N JACKSON AVE
Mailing Address - Street 2:# 101
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-1914
Mailing Address - Country:US
Mailing Address - Phone:408-258-6565
Mailing Address - Fax:408-258-1220
Practice Address - Street 1:125 N JACKSON AVE
Practice Address - Street 2:# 101
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1914
Practice Address - Country:US
Practice Address - Phone:408-258-6565
Practice Address - Fax:408-258-1220
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA020A80782207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX80780Medicaid
CA020A80783Medicare PIN
CA00AX80780Medicaid