1104802743 NPI number — MOHAMAD KADKHODA MD

Table of content: MOHAMAD KADKHODA MD (NPI 1104802743)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104802743 NPI number — MOHAMAD KADKHODA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KADKHODA
Provider First Name:
MOHAMAD
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104802743
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2450 W HUNTING PARK AVE FL 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19129-1302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-926-9022
Provider Business Mailing Address Fax Number:
215-226-8286

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 W LEHIGH AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19132-2701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-226-8800
Provider Business Practice Location Address Fax Number:
215-226-8819
Provider Enumeration Date:
12/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  MD034718L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: MD 034718L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000692373 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10021A . This is a "KMHP" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 5987421 . This is a "AETNA PPO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2098859 . This is a "AETNA HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: P00025017 . This is a "RR MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 114698 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0055553000 . This is a "INDEPENDENCE BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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