=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538170444
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOUSSA MOSHFEGH MD, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2006
-----------------------------------------------------
Last Update Date | 06/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6221 WILSHIRE BLVD SUITE # 404
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90048-5201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-933-3810
-----------------------------------------------------
Fax | 323-933-7522
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6221 WILSHIRE BLVD SUITE # 404
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90048-5201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-933-3810
-----------------------------------------------------
Fax | 323-933-7522
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. SHIDA MOOSIGHI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 323-933-3810
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | A38055
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------