Provider Demographics
NPI:1104874171
Name:MAHMOOD, TARIQ (MD)
Entity type:Individual
Prefix:
First Name:TARIQ
Middle Name:
Last Name:MAHMOOD
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 1:1010 W LA VETA AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4303
Mailing Address - Country:US
Mailing Address - Phone:714-541-6622
Mailing Address - Fax:714-541-0531
Practice Address - Street 1:1010 W LA VETA AVE STE 250
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4303
Practice Address - Country:US
Practice Address - Phone:714-541-6622
Practice Address - Fax:714-541-0531
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34660174400000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0057460Medicaid
WA34660BOtherPTAN
CAGR0057460Medicaid