Healthcare Provider Details

I. General information

NPI: 1851393300
Provider Name (Legal Business Name): HESSAM MAHDAVI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70390 HIGHWAY 111 STE 106
RANCHO MIRAGE CA
92270-5107
US

IV. Provider business mailing address

78120 WILDCAT DR
PALM DESERT CA
92211-1140
US

V. Phone/Fax

Practice location:
  • Phone: 760-674-3818
  • Fax: 760-773-4167
Mailing address:
  • Phone: 760-340-2682
  • Fax: 760-773-9695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC52222
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: