Provider Demographics
NPI:1811958424
Name:MOGHADDAM, MARYAM LEE (DO)
Entity type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:LEE
Last Name:MOGHADDAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16973 WEAVER LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-1435
Mailing Address - Country:US
Mailing Address - Phone:612-670-5214
Mailing Address - Fax:
Practice Address - Street 1:14500 99TH AVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4730
Practice Address - Country:US
Practice Address - Phone:763-898-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN31579207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN309397200Medicaid
160000936Medicare ID - Type Unspecified
MN309397200Medicaid