Provider Demographics
NPI:1912904376
Name:MOADAB, ANOOSH (DPM)
Entity type:Individual
Prefix:DR
First Name:ANOOSH
Middle Name:
Last Name:MOADAB
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6115 N 1ST ST STE 101
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-5450
Mailing Address - Country:US
Mailing Address - Phone:559-436-1213
Mailing Address - Fax:559-436-4202
Practice Address - Street 1:6115 N 1ST ST STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5450
Practice Address - Country:US
Practice Address - Phone:559-436-1213
Practice Address - Fax:559-436-4202
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4514213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00E45140OtherBLUE SHIELD
611685600OtherDEPARTMENT OF LABOR
CAE45140OtherBLUE CROSS
CA000E45140Medicaid
611685600OtherDEPARTMENT OF LABOR
CA00E45140OtherBLUE SHIELD
CA000E45140Medicaid
CAE45140OtherBLUE CROSS