Healthcare Provider Details

I. General information

NPI: 1346737178
Provider Name (Legal Business Name): ALI MAHDAVI FARD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 N ORANGE GROVE BLVD
PASADENA CA
91103-3534
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 626-817-4747
  • Fax: 626-817-4748
Mailing address:
  • Phone: 310-301-5138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA177153
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: