Provider Demographics
NPI:1699743625
Name:MOHAMMADZADEH, GHOLAM REZA (MD)
Entity type:Individual
Prefix:DR
First Name:GHOLAM
Middle Name:REZA
Last Name:MOHAMMADZADEH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:77 ROLLING OAKS DR STE 202
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91361-1018
Mailing Address - Country:US
Mailing Address - Phone:805-379-6717
Mailing Address - Fax:805-379-6719
Practice Address - Street 1:77 ROLLING OAKS DR STE 202
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91361-1018
Practice Address - Country:US
Practice Address - Phone:805-379-6717
Practice Address - Fax:805-379-6719
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG74293208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G742930Medicaid
CA00G742930Medicaid
CAWG74293BMedicare PIN
WG74293DMedicare ID - Type Unspecified
WG74293CMedicare ID - Type Unspecified