Healthcare Provider Details

I. General information

NPI: 1609459239
Provider Name (Legal Business Name): MOHAMMAD PAKRAVAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2021
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11370 ANDERSON ST # 1800
LOMA LINDA CA
92354-3450
US

IV. Provider business mailing address

11370 ANDERSON ST # 1800
LOMA LINDA CA
92354-3450
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-2154
  • Fax: 909-558-2180
Mailing address:
  • Phone: 909-558-2154
  • Fax: 909-558-2180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License NumberSFP54
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License NumberV5114
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberV5114
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: