Healthcare Provider Details

I. General information

NPI: 1568043156
Provider Name (Legal Business Name): DANIEL MOSALLAEI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2021
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 EASTLAKE AVE
LOS ANGELES CA
90089-1019
US

IV. Provider business mailing address

1441 EASTLAKE AVE
LOS ANGELES CA
90089-1019
US

V. Phone/Fax

Practice location:
  • Phone: 949-296-5780
  • Fax:
Mailing address:
  • Phone: 323-409-3360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA188209
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: