Provider Demographics
NPI:1538366406
Name:OMIDI, MOJDEH (LAC)
Entity type:Individual
Prefix:MISS
First Name:MOJDEH
Middle Name:
Last Name:OMIDI
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9270 TOWNE CENTRE DR UNIT 39
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-3011
Mailing Address - Country:US
Mailing Address - Phone:858-552-8937
Mailing Address - Fax:
Practice Address - Street 1:5665 OBERLIN DR STE 104
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1739
Practice Address - Country:US
Practice Address - Phone:858-722-5522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 5069171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist