Provider Demographics
NPI:1871900399
Name:FARDGHASSEMI, MOHAMMAD
Entity type:Individual
Prefix:MR
First Name:MOHAMMAD
Middle Name:
Last Name:FARDGHASSEMI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 E 17TH ST
Mailing Address - Street 2:SUITE 170
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-3824
Mailing Address - Country:US
Mailing Address - Phone:949-650-5990
Mailing Address - Fax:949-423-0300
Practice Address - Street 1:230 E 17TH ST
Practice Address - Street 2:SUITE 170
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3824
Practice Address - Country:US
Practice Address - Phone:949-650-5990
Practice Address - Fax:949-423-0300
Is Sole Proprietor?:No
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA 7409237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist