Basic Information
| Provider Information | |||||||||
| NPI: | 1376625426 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOGHADDAS | ||||||||
| FirstName: | NIMA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 37 PALMER ST | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | CALAIS | ||||||||
| State: | ME | ||||||||
| PostalCode: | 046191305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074548195 | ||||||||
| FaxNumber: | 2074543840 | ||||||||
| Practice Location | |||||||||
| Address1: | 37 PALMER ST | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | CALAIS | ||||||||
| State: | ME | ||||||||
| PostalCode: | 046191305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074548195 | ||||||||
| FaxNumber: | 2074543840 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213EP1101X | POD1001 | ME | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 235700099 | 05 | ME | MEDICAID | POD1001 | 01 | ME | STATE LICENSE | OTHER |