Basic Information
| Provider Information | |||||||||
| NPI: | 1053415182 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOTAMED | ||||||||
| FirstName: | MEHRAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M,D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 31086 LARCHWOOD ST | ||||||||
| Address2: | |||||||||
| City: | MENIFEE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925848702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185511378 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 950 N RAMONA BLVD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | SAN JACINTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925822567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185511378 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2006 | ||||||||
| LastUpdateDate: | 11/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | A89851 | CA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0800X | A89851 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.