Provider Demographics
NPI:1588757074
Name:DADSETAN, MOHAMMAD REZA (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:REZA
Last Name:DADSETAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 S GLENOAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91502
Mailing Address - Country:US
Mailing Address - Phone:818-843-1919
Mailing Address - Fax:818-843-3587
Practice Address - Street 1:225 S GLENOAKS BLVD
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91502
Practice Address - Country:US
Practice Address - Phone:818-843-1919
Practice Address - Fax:818-843-3587
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA490922085R0202X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA49092OtherMEDICAL CERTIFICATE
CA00A490920Medicaid
CA00A490920Medicaid
A49092Medicare ID - Type Unspecified