Provider Demographics
NPI:1801972716
Name:MOOSAVI, REY (MD)
Entity type:Individual
Prefix:MR
First Name:REY
Middle Name:
Last Name:MOOSAVI
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 1:1333 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-6540
Mailing Address - Country:US
Mailing Address - Phone:619-447-6001
Mailing Address - Fax:619-447-6096
Practice Address - Street 1:1333 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-6540
Practice Address - Country:US
Practice Address - Phone:619-447-6001
Practice Address - Fax:619-447-6096
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35706208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A357060Medicaid
CA00A357060Medicaid
CAA35706AMedicare ID - Type Unspecified