Provider Demographics
NPI:1043326234
Name:NOUSHKAM, MOHAMAD BAGHER (MD)
Entity type:Individual
Prefix:
First Name:MOHAMAD
Middle Name:BAGHER
Last Name:NOUSHKAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:438 E KATELLA AVE
Mailing Address - Street 2:STE B
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-4839
Mailing Address - Country:US
Mailing Address - Phone:714-744-5000
Mailing Address - Fax:714-744-5985
Practice Address - Street 1:555 N STATE COLLEGE BLVD
Practice Address - Street 2:STE 100
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-2900
Practice Address - Country:US
Practice Address - Phone:714-520-8470
Practice Address - Fax:714-520-8471
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA45935207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA45935OtherMEDICAL LICENSE
CAE28341Medicare UPIN