Healthcare Provider Details

I. General information

NPI: 1164587713
Provider Name (Legal Business Name): ALI MOHAMMAD MOVAFAGH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12712 HEACOCK ST STE 1
MORENO VALLEY CA
92553
US

IV. Provider business mailing address

12712 HEACOCK ST STE 1
MORENO VALLEY CA
92553
US

V. Phone/Fax

Practice location:
  • Phone: 951-485-0335
  • Fax: 951-485-1514
Mailing address:
  • Phone: 951-485-0335
  • Fax: 951-485-1514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC42507
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC42507
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: