Healthcare Provider Details

I. General information

NPI: 1245446228
Provider Name (Legal Business Name): SEPI MAHOOTI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 12/27/2021
Certification Date: 12/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13922 MENNONITE PT
SAN DIEGO CA
92129-3134
US

IV. Provider business mailing address

13922 MENNONITE PT
SAN DIEGO CA
92129-3134
US

V. Phone/Fax

Practice location:
  • Phone: 203-506-7862
  • Fax:
Mailing address:
  • Phone: 203-506-7862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number35.089487
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License NumberA109898
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number35.089487
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: