Basic Information
Provider Information | |||||||||
NPI: | 1326445347 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KAVEH-TALLEY | ||||||||
FirstName: | MOJGAN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KAVEH | ||||||||
OtherFirstName: | MOJGAN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 5100 NORTH PIEDRAS STREET | ||||||||
Address2: |   | ||||||||
City: | EL PASO | ||||||||
State: | TX | ||||||||
PostalCode: | 79930 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9155646100 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5100 NORTH PIEDRAS STREET | ||||||||
Address2: |   | ||||||||
City: | EL PASO | ||||||||
State: | TX | ||||||||
PostalCode: | 79930 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9155646100 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/20/2014 | ||||||||
LastUpdateDate: | 08/10/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/10/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD-18277 | HI | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 117312 | FL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.