Provider Demographics
NPI:1740274869
Name:FARHADIEH MORALES, MANDANA (MD, PC)
Entity type:Individual
Prefix:DR
First Name:MANDANA
Middle Name:
Last Name:FARHADIEH MORALES
Suffix:
Gender:F
Credentials:MD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6401 STARGAZE LN STE 106
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-0802
Mailing Address - Country:US
Mailing Address - Phone:704-591-7196
Mailing Address - Fax:847-548-9909
Practice Address - Street 1:6401 STARGAZE LN STE 106
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-0802
Practice Address - Country:US
Practice Address - Phone:704-591-7196
Practice Address - Fax:704-464-1818
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-02
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC02000068208000000X
SCMD83399208000000X
IL0361032582080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036103258Medicaid