Healthcare Provider Details

I. General information

NPI: 1225235237
Provider Name (Legal Business Name): LIDA MOHTASHAM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 ATLANTIC AVE
LONG BEACH CA
90806-1701
US

IV. Provider business mailing address

PO BOX 3637
SEAL BEACH CA
90740-7637
US

V. Phone/Fax

Practice location:
  • Phone: 562-684-8096
  • Fax:
Mailing address:
  • Phone: 562-684-8096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD434388
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License NumberMT205387
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License NumberMD434388
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: