Provider Demographics
NPI:1487712071
Name:MOSADDEGH, LILLIE AKRAM (MD)
Entity type:Individual
Prefix:
First Name:LILLIE
Middle Name:AKRAM
Last Name:MOSADDEGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 W PORTAL AVE STE B
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94127-1428
Mailing Address - Country:US
Mailing Address - Phone:415-285-3895
Mailing Address - Fax:410-392-8622
Practice Address - Street 1:380 W PORTAL AVE
Practice Address - Street 2:STE B
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94127-1428
Practice Address - Country:US
Practice Address - Phone:415-285-3895
Practice Address - Fax:410-392-8622
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79847207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G798470OtherBLUE SHIELD
CA00G798470Medicaid
CA00G798470Medicaid
00G798470OtherBLUE SHIELD