Provider Demographics
NPI:1104802743
Name:KADKHODA, MOHAMAD (MD)
Entity type:Individual
Prefix:
First Name:MOHAMAD
Middle Name:
Last Name:KADKHODA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 W HUNTING PARK AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-926-9022
Mailing Address - Fax:215-226-8286
Practice Address - Street 1:1300 W LEHIGH AVE
Practice Address - Street 2:SUITE B
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19132-2701
Practice Address - Country:US
Practice Address - Phone:215-226-8800
Practice Address - Fax:215-226-8819
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD034718L208000000X
PAMD 034718L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000692373Medicaid
PA10021AOtherKMHP
PA5987421OtherAETNA PPO
PA2098859OtherAETNA HMO
PAP00025017OtherRR MEDICARE
PA114698OtherHIGHMARK BLUE SHIELD
PA0055553000OtherINDEPENDENCE BLUE CROSS
PA10021AOtherKMHP
PA5987421OtherAETNA PPO