=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942430806
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID MOOSSAZADEH DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2009
-----------------------------------------------------
Last Update Date | 09/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11540 SANTA MONICA BLVD SUITE 204
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-774-3254
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11540 SANTA MONICA BLVD SUITE 204
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-774-3254
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 20A11456
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------