Provider Demographics
NPI:1689788234
Name:MOUSSAVIAN, MEHRAN (DO)
Entity type:Individual
Prefix:
First Name:MEHRAN
Middle Name:
Last Name:MOUSSAVIAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:754 MEDICAL CENTER CT
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-6654
Mailing Address - Country:US
Mailing Address - Phone:619-616-2100
Mailing Address - Fax:619-616-2104
Practice Address - Street 1:765 MEDICAL CENTER CT STE 211
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-6600
Practice Address - Country:US
Practice Address - Phone:619-616-2100
Practice Address - Fax:619-616-2104
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7241207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH21053Medicare UPIN