Provider Demographics
NPI:1134166010
Name:RASSOULI, MOHAMMAD E (MD)
Entity type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:E
Last Name:RASSOULI
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 1:25982 PALA STE 170
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6736
Mailing Address - Country:US
Mailing Address - Phone:949-716-6134
Mailing Address - Fax:949-266-9719
Practice Address - Street 1:25982 PALA STE 170
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691
Practice Address - Country:US
Practice Address - Phone:949-716-6134
Practice Address - Fax:949-266-9719
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA505872084N0400X
WI31479-0202084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31647900Medicaid
F23788Medicare UPIN
WI000073794Medicare PIN