Provider Demographics
NPI:1104071380
Name:MOJAB, MOZHGAN
Entity type:Individual
Prefix:
First Name:MOZHGAN
Middle Name:
Last Name:MOJAB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3670 BARRY AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-3202
Mailing Address - Country:US
Mailing Address - Phone:310-621-4595
Mailing Address - Fax:310-390-3883
Practice Address - Street 1:3670 BARRY AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-3202
Practice Address - Country:US
Practice Address - Phone:310-621-4595
Practice Address - Fax:310-390-3883
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT19312225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18826OtherMEDICARE PROVIDER