Healthcare Provider Details

I. General information

NPI: 1841404175
Provider Name (Legal Business Name): TAKAHIRO MORI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 04/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10945 LE CONTE AVE STE. 2339
LOS ANGELES CA
90095-1687
US

IV. Provider business mailing address

10945 LE CONTE AVE STE. 2339
LOS ANGELES CA
90095-1687
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-5421
  • Fax:
Mailing address:
  • Phone: 310-825-5421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberA110588
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: