Healthcare Provider Details

I. General information

NPI: 1134036106
Provider Name (Legal Business Name): NASTARAN POURDEHMOBED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 W BROADWAY
SAN DIEGO CA
92101-3536
US

IV. Provider business mailing address

501 W BROADWAY
SAN DIEGO CA
92101-3536
US

V. Phone/Fax

Practice location:
  • Phone: 858-488-3597
  • Fax: 858-724-1747
Mailing address:
  • Phone: 858-488-3597
  • Fax: 858-724-1747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number310619
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: