=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538333729
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAZDA MOTALLEBI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2008
-----------------------------------------------------
Last Update Date | 10/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10000 LAKEWOOD BLVD
-----------------------------------------------------
City | DOWNEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90240-4020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-862-3684
-----------------------------------------------------
Fax | 562-231-1904
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12900 PARK PLAZA DR STE 150
-----------------------------------------------------
City | CERRITOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90703-9329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-977-4639
-----------------------------------------------------
Fax | 714-741-4479
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | A84184
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RC0001X
-----------------------------------------------------
Taxonomy Name | Clinical Cardiac Electrophysiology Physician
-----------------------------------------------------
License Number | 61298
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------