Provider Demographics
NPI:1780776740
Name:MAMAD BAGHERI MD INC
Entity type:Organization
Organization Name:MAMAD BAGHERI MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAMAD
Authorized Official - Middle Name:MIRZA
Authorized Official - Last Name:BAGHERI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-766-1188
Mailing Address - Street 1:PO BOX 5363
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92544-0363
Mailing Address - Country:US
Mailing Address - Phone:951-766-1188
Mailing Address - Fax:951-766-1388
Practice Address - Street 1:2390 E FLORIDA AVE STE 204
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92544-4754
Practice Address - Country:US
Practice Address - Phone:951-766-1188
Practice Address - Fax:951-766-1388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82406207ND0101X, 207ND0900X, 207NI0002X, 207NP0225X, 207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological ImmunologyGroup - Multi-Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00346003OtherRAILROAD MEDICARE
DF1942OtherRAILROAD MEDICARE
112713370OtherAETNA
CAA82406OtherCA LICENSE
112713370OtherAETNA
CAZZZ30167ZMedicare PIN