Healthcare Provider Details

I. General information

NPI: 1538333729
Provider Name (Legal Business Name): MAZDA MOTALLEBI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2008
Last Update Date: 07/03/2026
Certification Date: 07/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3737 MARTIN LUTHER KING JR BLVD STE 401
LYNWOOD CA
90262-3534
US

IV. Provider business mailing address

830 PENN ST
EL SEGUNDO CA
90245-2511
US

V. Phone/Fax

Practice location:
  • Phone: 310-604-0443
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number77552
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number77552
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number61298
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberA84184
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number77552
License Number StateTN
# 6
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberA84184
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: