=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104802743
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOHAMAD KADKHODA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2005
-----------------------------------------------------
Last Update Date | 01/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 W LEHIGH AVE SUITE B
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19132-2701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-226-8800
-----------------------------------------------------
Fax | 215-226-8819
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2450 W HUNTING PARK AVE FL 2
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19129-1302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-926-9022
-----------------------------------------------------
Fax | 215-226-8286
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | MD034718L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | MD 034718L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------