Provider Demographics
NPI:1548372824
Name:AZADEH, MINOO (MD)
Entity type:Individual
Prefix:
First Name:MINOO
Middle Name:
Last Name:AZADEH
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 1:8902 WOODMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ARLETA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-6401
Mailing Address - Country:US
Mailing Address - Phone:818-830-7033
Mailing Address - Fax:818-891-0953
Practice Address - Street 1:11254 GOTHIC AVE
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-3709
Practice Address - Country:US
Practice Address - Phone:818-368-4442
Practice Address - Fax:818-368-5053
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38738208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70468FMedicaid
CAA38738OtherLICENSE #