Provider Demographics
NPI:1588414148
Name:MOGHADDAM, MARJAN
Entity type:Individual
Prefix:
First Name:MARJAN
Middle Name:
Last Name:MOGHADDAM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3869 MIRAMAR ST APT 3810
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92092-0004
Mailing Address - Country:US
Mailing Address - Phone:926-936-9691
Mailing Address - Fax:
Practice Address - Street 1:3869 MIRAMAR ST APT 3810
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92092-0004
Practice Address - Country:US
Practice Address - Phone:926-936-9691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-26
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program