Healthcare Provider Details

I. General information

NPI: 1780776740
Provider Name (Legal Business Name): MAMAD BAGHERI MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 05/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2390 E FLORIDA AVE STE 204
HEMET CA
92544-4754
US

IV. Provider business mailing address

PO BOX 5363
HEMET CA
92544-0363
US

V. Phone/Fax

Practice location:
  • Phone: 951-766-1188
  • Fax: 951-766-1388
Mailing address:
  • Phone: 951-766-1188
  • Fax: 951-766-1388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA82406
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberA82406
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberA82406
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License NumberA82406
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberA82406
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberA82406
License Number StateCA

VIII. Authorized Official

Name: MAMAD MIRZA BAGHERI
Title or Position: OWNER/PRESIDENT
Credential: M.D.
Phone: 951-766-1188