Provider Demographics
NPI:1871543850
Name:MOHIDEEN, NAMITA P (MD)
Entity type:Individual
Prefix:DR
First Name:NAMITA
Middle Name:P
Last Name:MOHIDEEN
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 1:16465 SIERRA LAKES PKWY STE 115
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-1242
Mailing Address - Country:US
Mailing Address - Phone:909-823-8000
Mailing Address - Fax:909-823-8088
Practice Address - Street 1:16465 SIERRA LAKES PKWY STE 115
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-1242
Practice Address - Country:US
Practice Address - Phone:909-823-8000
Practice Address - Fax:909-823-8088
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55769208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A557690Medicaid
CA1871543850Medicaid
CA1174760953Medicaid
CAZZZ01339ZOtherBS/TRIWEST
CAZZZ39356ZOtherBS/TRIWEST
CA1518136787Medicaid
CA00A557690Medicaid
CAZZZ39356ZOtherBS/TRIWEST