Provider Demographics
NPI:1447946645
Name:ROSHANDEL MOGHADDAM, MOHAMMAD REZA (MD)
Entity type:Individual
Prefix:
First Name:MOHAMMAD REZA
Middle Name:
Last Name:ROSHANDEL MOGHADDAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:M. REZA
Other - Middle Name:
Other - Last Name:ROSHANDEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1901 26TH AVE NW APT 17
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-8031
Mailing Address - Country:US
Mailing Address - Phone:929-398-1772
Mailing Address - Fax:
Practice Address - Street 1:100 WOODS RD
Practice Address - Street 2:
Practice Address - City:VALHALLA
Practice Address - State:NY
Practice Address - Zip Code:10595-1530
Practice Address - Country:US
Practice Address - Phone:914-493-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-12
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program