Healthcare Provider Details

I. General information

NPI: 1083238752
Provider Name (Legal Business Name): MAHON MAHMODIAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2020
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78120 WILDCAT DR
PALM DESERT CA
92211-1140
US

IV. Provider business mailing address

78120 WILDCAT DR
PALM DESERT CA
92211-1140
US

V. Phone/Fax

Practice location:
  • Phone: 760-340-2682
  • Fax: 760-773-9695
Mailing address:
  • Phone: 760-340-2682
  • Fax: 760-773-9695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number20A21009
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A21009
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: