Provider Demographics
NPI:1912165903
Name:EHTEMAM, MOJGAN (RD)
Entity type:Individual
Prefix:MRS
First Name:MOJGAN
Middle Name:
Last Name:EHTEMAM
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 DORCHESTER W
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-2618
Mailing Address - Country:US
Mailing Address - Phone:949-857-4557
Mailing Address - Fax:
Practice Address - Street 1:33 CREEK RD
Practice Address - Street 2:SUITE 260 B
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-4791
Practice Address - Country:US
Practice Address - Phone:949-857-4557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-28
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA666363133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered