Provider Demographics
NPI:1457615247
Name:MOGHADDAM, MARJAN (DO)
Entity type:Individual
Prefix:
First Name:MARJAN
Middle Name:
Last Name:MOGHADDAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4077 CROOKS RD
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-2481
Mailing Address - Country:US
Mailing Address - Phone:248-595-2328
Mailing Address - Fax:
Practice Address - Street 1:3370 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-4236
Practice Address - Country:US
Practice Address - Phone:800-659-6568
Practice Address - Fax:313-656-1610
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2021-03-09
Deactivation Date:2018-10-22
Deactivation Code:
Reactivation Date:2018-11-21
Provider Licenses
StateLicense IDTaxonomies
MI5101019748207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003187944AMedicaid