Healthcare Provider Details

I. General information

NPI: 1609863091
Provider Name (Legal Business Name): MINA MOUSSAVIAN-ASSADI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MINA MOUSSAVIAN MD

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 08/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5525 ETIWANDA AVE #212
TARZANA CA
91356-3647
US

IV. Provider business mailing address

PO BOX 9602
MISSION HILLS CA
91346-9602
US

V. Phone/Fax

Practice location:
  • Phone: 818-721-2400
  • Fax:
Mailing address:
  • Phone: 818-837-5559
  • Fax: 818-792-4793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number216492
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: