Healthcare Provider Details

I. General information

NPI: 1164513677
Provider Name (Legal Business Name): MORTEZA CHITSAZAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26520 CACTUS AVE
MORENO VALLEY CA
92555-3927
US

IV. Provider business mailing address

PO BOX 7270
MORENO VALLEY CA
92552-7270
US

V. Phone/Fax

Practice location:
  • Phone: 951-486-5700
  • Fax: 951-486-5705
Mailing address:
  • Phone: 951-486-5700
  • Fax: 951-486-5705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number20A7819
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: