Provider Demographics
NPI:1992707004
Name:MODARESI, AZADEH (MD)
Entity type:Individual
Prefix:DR
First Name:AZADEH
Middle Name:
Last Name:MODARESI
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:PO BOX 547
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91365-0547
Mailing Address - Country:US
Mailing Address - Phone:818-668-8898
Mailing Address - Fax:918-668-8893
Practice Address - Street 1:6730A WHITE OAK AVE
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406
Practice Address - Country:US
Practice Address - Phone:818-668-8898
Practice Address - Fax:818-668-8893
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70235207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA70235Medicaid
CAWA70235BMedicare ID - Type Unspecified
CAA70235Medicaid