Healthcare Provider Details

I. General information

NPI: 1386221703
Provider Name (Legal Business Name): FREDERICK VAN MOH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2021
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 PARNASSUS AVE FL 3
SAN FRANCISCO CA
94143-2204
US

IV. Provider business mailing address

2051 MARENGO ST
LOS ANGELES CA
90033-1352
US

V. Phone/Fax

Practice location:
  • Phone: 415-514-5681
  • Fax:
Mailing address:
  • Phone: 323-409-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA182405
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: