Basic Information
Provider Information | |||||||||
NPI: | 1730185612 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HAGHVERDI | ||||||||
FirstName: | MOJDEH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 419430 | ||||||||
Address2: |   | ||||||||
City: | BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 022419430 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2016663900 | ||||||||
FaxNumber: | 2012610505 | ||||||||
Practice Location | |||||||||
Address1: | 1130 MCBRIDE AVE | ||||||||
Address2: |   | ||||||||
City: | WOODLAND PARK | ||||||||
State: | NJ | ||||||||
PostalCode: | 074243806 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9738378393 | ||||||||
FaxNumber: | 9738378394 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/24/2005 | ||||||||
LastUpdateDate: | 04/21/2017 | ||||||||
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 | 207R00000X | 25MA06252700 | NJ | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 2291876 | 01 | NJ | AETNA HMO | OTHER | 7726406 | 05 | NJ |   | MEDICAID | 38N681 | 01 | NJ | EMPIRE BC/BS | OTHER | 1K5312 | 01 | NJ | HEALTHNET | OTHER | 5745441 | 01 | NJ | AETNA PPO | OTHER | 2596457 | 01 | NJ | GHI PPO | OTHER | P1098368 | 01 | NJ | OXFORD | OTHER | 110204455 | 01 | NJ | RAILROAD MEDICARE | OTHER |