Provider Demographics
NPI:1891373247
Name:MOAZEZI, TINA (DO)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:MOAZEZI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W CARSON ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-2059
Mailing Address - Country:US
Mailing Address - Phone:310-222-1867
Mailing Address - Fax:310-533-0627
Practice Address - Street 1:1000 W CARSON ST
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2059
Practice Address - Country:US
Practice Address - Phone:310-222-1867
Practice Address - Fax:310-533-0627
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.077638207R00000X
390200000X
CA20A22616207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program