=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457300386
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAMIDREZA MOGHADDAM MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2006
-----------------------------------------------------
Last Update Date | 02/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 527 NE 124TH ST
-----------------------------------------------------
City | NORTH MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33161-5423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-895-9233
-----------------------------------------------------
Fax | 305-895-9274
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 527 NE 124TH ST
-----------------------------------------------------
City | NORTH MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33161-5423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-895-9233
-----------------------------------------------------
Fax | 305-895-9274
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | HAMIDREZA MOGHADDAM
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 305-895-9233
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | PO3670
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME91771
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------