Provider Demographics
NPI:1801950498
Name:PESHIMAM, MAHMOOD (MD)
Entity type:Individual
Prefix:DR
First Name:MAHMOOD
Middle Name:
Last Name:PESHIMAM
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 1:10900 WARNER AVE
Mailing Address - Street 2:#115
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-3846
Mailing Address - Country:US
Mailing Address - Phone:714-968-8600
Mailing Address - Fax:714-968-8564
Practice Address - Street 1:10900 WARNER AVE
Practice Address - Street 2:#115
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-3846
Practice Address - Country:US
Practice Address - Phone:714-968-8600
Practice Address - Fax:714-968-8564
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA36540207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA330245618OtherTAX ID
CA00A365400Medicaid
CA330245618OtherTAX ID
CAA36540Medicare PIN