Provider Demographics
NPI:1063726164
Name:EHSAN MOSHFEGH MD INC
Entity type:Organization
Organization Name:EHSAN MOSHFEGH MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EHSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSHFEGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-246-4172
Mailing Address - Street 1:10701 WILSHIRE BLVD
Mailing Address - Street 2:SUITE # 1103
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-4401
Mailing Address - Country:US
Mailing Address - Phone:310-246-4172
Mailing Address - Fax:
Practice Address - Street 1:1115 S ROBERTSON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-1403
Practice Address - Country:US
Practice Address - Phone:310-246-4171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-30
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42194208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A421940Medicaid
CA00A421940Medicaid
CAA42194Medicare PIN