Healthcare Provider Details

I. General information

NPI: 1932296340
Provider Name (Legal Business Name): MUSTAFA MAHDAVY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1117 E. DEVONSHIRE AVE. DEPARTMENT OF PATHOLOGY
HEMET CA
92543
US

IV. Provider business mailing address

1117 E. DEVONSHIRE AVE. DEPARTMENT OF PATHOLOGY
HEMET CA
92543
US

V. Phone/Fax

Practice location:
  • Phone: 985-789-7994
  • Fax: 951-765-4829
Mailing address:
  • Phone: 985-789-7994
  • Fax: 951-765-4829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberA93215
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: