Provider Demographics
NPI:1255402640
Name:MAHMOUDI, MASSOUD (DO)
Entity type:Individual
Prefix:DR
First Name:MASSOUD
Middle Name:
Last Name:MAHMOUDI
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 1:812 POLLARD RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-1420
Mailing Address - Country:US
Mailing Address - Phone:408-866-6885
Mailing Address - Fax:
Practice Address - Street 1:812 POLLARD RD
Practice Address - Street 2:SUITE 5
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-1420
Practice Address - Country:US
Practice Address - Phone:408-866-6885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7157207K00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0020A71570Medicaid
CA0020A71570Medicare PIN
CAG72015Medicare UPIN