Provider Demographics
NPI:1780773721
Name:MAHDAVI, HMA (MD)
Entity type:Individual
Prefix:DR
First Name:HMA
Middle Name:
Last Name:MAHDAVI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:HOMA
Other - Middle Name:MAHDAVI
Other - Last Name:PEZESHKIAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6101 BALL RD STE 310
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90630-3966
Mailing Address - Country:US
Mailing Address - Phone:714-220-9486
Mailing Address - Fax:714-220-9481
Practice Address - Street 1:1760 TERMINO AVE STE 214
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-2169
Practice Address - Country:US
Practice Address - Phone:562-933-6933
Practice Address - Fax:562-933-6939
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA727592080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A727590Medicare UPIN