Healthcare Provider Details

I. General information

NPI: 1629095468
Provider Name (Legal Business Name): MEHDI MOSADEGH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 10/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2104 GAUSE BLVD W STE. A
SLIDELL LA
70460-4130
US

IV. Provider business mailing address

2104 GAUSE BLVD W STE. A
SLIDELL LA
70460-4130
US

V. Phone/Fax

Practice location:
  • Phone: 985-643-4575
  • Fax: 985-643-4513
Mailing address:
  • Phone: 985-643-4512
  • Fax: 985-643-4513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number13020
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: