Provider Demographics
NPI:1174535918
Name:MOINZADEH, ALIREZA (MD)
Entity type:Individual
Prefix:
First Name:ALIREZA
Middle Name:
Last Name:MOINZADEH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 MALL RD
Mailing Address - Street 2:DEPARTMENT OF UROLOGY
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0002
Mailing Address - Country:US
Mailing Address - Phone:781-744-8334
Mailing Address - Fax:781-744-5429
Practice Address - Street 1:41 MALL RD
Practice Address - Street 2:DEPARTMENT OF UROLOGY
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805-0001
Practice Address - Country:US
Practice Address - Phone:781-744-8334
Practice Address - Fax:781-744-5429
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA160895208800000X
NH14771208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110077501AMedicaid
NH30209387Medicaid
MA000234401Medicare PIN
MA110077501AMedicaid
MA000234402Medicare PIN