Provider Demographics
NPI:1396758942
Name:MOGHADAM, MARIAM S (MD)
Entity type:Individual
Prefix:DR
First Name:MARIAM
Middle Name:S
Last Name:MOGHADAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:200 OCEANGATE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4317
Mailing Address - Country:US
Mailing Address - Phone:909-498-2356
Mailing Address - Fax:877-824-9080
Practice Address - Street 1:1181 N MOUNT VERNON AVE
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-2574
Practice Address - Country:US
Practice Address - Phone:909-498-2356
Practice Address - Fax:877-824-9080
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2023-03-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA86456207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP01288539/DU5182OtherRAILROAD MEDICARE-COLTON
CAP01288539/DU4034OtherRAILROAD MEDICARE-RIALTO
CAP01288539/DU4034OtherRAILROAD MEDICARE-RIALTO
CAP01288539/DU4034OtherRAILROAD MEDICARE-RIALTO
CAI19355Medicare UPIN
CABM8774172OtherDEA