Provider Demographics
NPI:1972893501
Name:MOAZAMI, NEGAR REBECCA (MD)
Entity type:Individual
Prefix:
First Name:NEGAR
Middle Name:REBECCA
Last Name:MOAZAMI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2107 KNOB HILL DR
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:TX
Mailing Address - Zip Code:76210-1918
Mailing Address - Country:US
Mailing Address - Phone:214-477-5584
Mailing Address - Fax:
Practice Address - Street 1:3600 GASTON AVE
Practice Address - Street 2:SUITE 550
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1800
Practice Address - Country:US
Practice Address - Phone:214-820-2361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-16
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXP5688207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program