Healthcare Provider Details

I. General information

NPI: 1497963722
Provider Name (Legal Business Name): LINDA MOGHTADER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12300 WILSHIRE BLVD SUITE 330
LOS ANGELES CA
90025-1020
US

IV. Provider business mailing address

12300 WILSHIRE BLVD SUITE 330
LOS ANGELES CA
90025-1020
US

V. Phone/Fax

Practice location:
  • Phone: 310-442-7601
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License NumberG56261
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: