Provider Demographics
NPI:1538333729
Name:MOTALLEBI, MAZDA (MD)
Entity type:Individual
Prefix:
First Name:MAZDA
Middle Name:
Last Name:MOTALLEBI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:12900 PARK PLAZA DR STE 150
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-9329
Mailing Address - Country:US
Mailing Address - Phone:562-977-4639
Mailing Address - Fax:714-741-4479
Practice Address - Street 1:10000 LAKEWOOD BLVD
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90240-4020
Practice Address - Country:US
Practice Address - Phone:562-862-3684
Practice Address - Fax:562-231-1904
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-17
Last Update Date:2019-08-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA84184207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACR491TMedicare PIN
CACR491SMedicare PIN