Healthcare Provider Details

I. General information

NPI: 1841365921
Provider Name (Legal Business Name): MAHMOOD MOSTOUFI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 E 17TH ST STE E 110
SANTA ANA CA
92701-2214
US

IV. Provider business mailing address

1125 E 17TH ST STE E 110
SANTA ANA CA
92701-2214
US

V. Phone/Fax

Practice location:
  • Phone: 714-550-0110
  • Fax: 714-550-0737
Mailing address:
  • Phone: 714-550-0110
  • Fax: 714-550-0737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA39664
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: