Healthcare Provider Details

I. General information

NPI: 1740274869
Provider Name (Legal Business Name): MANDANA FARHADIEH MORALES MD, PC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2005
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 STARGAZE LN STE 106
CHARLOTTE NC
28269-0802
US

IV. Provider business mailing address

6401 STARGAZE LN STE 106
CHARLOTTE NC
28269-0802
US

V. Phone/Fax

Practice location:
  • Phone: 704-591-7196
  • Fax: 704-464-1818
Mailing address:
  • Phone: 704-591-7196
  • Fax: 847-548-9909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number02000068
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD83399
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number036103258
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: