Healthcare Provider Details

I. General information

NPI: 1912904376
Provider Name (Legal Business Name): ANOOSH MOADAB D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 04/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6115 N 1ST ST STE 101
FRESNO CA
93710-5450
US

IV. Provider business mailing address

6115 N 1ST ST STE 101
FRESNO CA
93710-5450
US

V. Phone/Fax

Practice location:
  • Phone: 559-436-1213
  • Fax: 559-436-4202
Mailing address:
  • Phone: 559-436-1213
  • Fax: 559-436-4202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE4514
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: