Basic Information
| Provider Information | |||||||||
| NPI: | 1457615247 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOGHADDAM | ||||||||
| FirstName: | MARJAN | ||||||||
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| Credential: | D.O | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4077 CROOKS RD | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480732481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485952328 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3370 E JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482074236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006596568 | ||||||||
| FaxNumber: | 3136561610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2012 | ||||||||
| LastUpdateDate: | 03/09/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 10/22/2018 | ||||||||
| NPIReactivationDate: | 11/21/2018 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101019748 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.