Healthcare Provider Details

I. General information

NPI: 1679625222
Provider Name (Legal Business Name): MEHDI AMINI MOGHADAM MID
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7232 VAN NUYS BLVD SUITE 201
VAN NUYS CA
91405
US

IV. Provider business mailing address

7232 VAN NUYS BLVD SUITE 201
VAN NUYS CA
91405
US

V. Phone/Fax

Practice location:
  • Phone: 818-373-4999
  • Fax: 818-373-4998
Mailing address:
  • Phone: 818-373-4999
  • Fax: 818-373-4998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC43315
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: