Healthcare Provider Details

I. General information

NPI: 1205652146
Provider Name (Legal Business Name): MOKHTARE MD, PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2024
Last Update Date: 10/24/2025
Certification Date: 10/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2865 E COAST HWY UNIT 120
CORONA DEL MAR CA
92625-2236
US

IV. Provider business mailing address

3141 MICHELSON DR UNIT 1704
IRVINE CA
92612-5675
US

V. Phone/Fax

Practice location:
  • Phone: 866-278-2204
  • Fax:
Mailing address:
  • Phone: 949-287-6357
  • Fax: 888-462-5010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SHAHRZAD MOKHTARE
Title or Position: PRESIDENT
Credential: MD
Phone: 949-735-1632