Basic Information
| Provider Information | |||||||||
| NPI: | 1568503191 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOGHADDAM SMOOT | ||||||||
| FirstName: | MAHSA | ||||||||
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| Credential: | MBBS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2925 CHICAGO AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554071321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122625000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1601 SAINT FRANCIS AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | SHAKOPEE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553793384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524283535 | ||||||||
| FaxNumber: | 9524283599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | 49671 | MN | N | Allopathic & Osteopathic Physicians | Plastic Surgery | 208600000X | 49671 | MN | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0122X | 49671 | MN | Y | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 49671 | 01 | MN | MEDICAL LICENSE | OTHER | 307488000 | 05 | MN | MEDICAID |