Provider Demographics
NPI:1194771337
Name:SHOJAEI-MOGHADDAM, JALIL (MD)
Entity type:Individual
Prefix:DR
First Name:JALIL
Middle Name:
Last Name:SHOJAEI-MOGHADDAM
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 1:27555 MIDDLEBELT RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-5011
Mailing Address - Country:US
Mailing Address - Phone:248-478-5512
Mailing Address - Fax:248-478-5350
Practice Address - Street 1:27555 MIDDLEBELT RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-5011
Practice Address - Country:US
Practice Address - Phone:248-478-5512
Practice Address - Fax:248-478-5350
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36234174400000X, 2084S0012X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No174400000XOther Service ProvidersSpecialist
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64941289Medicaid
KY1280117Medicare ID - Type Unspecified
KY64941289Medicaid