Provider Demographics
NPI:1073728051
Name:MOSTOFI, TARA (PAC)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:MOSTOFI
Suffix:
Gender:
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 N. WIGET LANE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-2452
Mailing Address - Country:US
Mailing Address - Phone:925-935-6252
Mailing Address - Fax:925-930-0942
Practice Address - Street 1:370 N. WIGET LANE
Practice Address - Street 2:SUITE 210
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-2452
Practice Address - Country:US
Practice Address - Phone:925-935-6252
Practice Address - Fax:925-930-0942
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17957207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine