Healthcare Provider Details

I. General information

NPI: 1760416770
Provider Name (Legal Business Name): MOHAMMAD IMANDOUST M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3762 MISSION TRAIL SUITE F
LAKE ELSINORE CA
92530
US

IV. Provider business mailing address

16222 TURTLEBACK RD
SAN DIEGO CA
92127-2013
US

V. Phone/Fax

Practice location:
  • Phone: 951-674-5686
  • Fax: 951-674-4707
Mailing address:
  • Phone: 858-673-4553
  • Fax: 858-673-4553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC50910
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: