Basic Information
| Provider Information | |||||||||
| NPI: | 1689815888 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOIDUDDIN | ||||||||
| FirstName: | NASSER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOIDUDDIN | ||||||||
| OtherFirstName: | NASSER | ||||||||
| OtherMiddleName: | JUNAID | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 725 WELCH RD | ||||||||
| Address2: | |||||||||
| City: | PALO ALTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 943041601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6504978000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 725 WELCH RD | ||||||||
| Address2: | |||||||||
| City: | PALO ALTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 943041601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6504978000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2009 | ||||||||
| LastUpdateDate: | 02/24/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0002X | A109143 | CA | N | 207RA0002X | MD2021-0101 | NM | N | 208000000X | 4301087407 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | A109143 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0202X | 4301087407 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 2080P0202X | 27237 | WV | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 2080P0202X | 35094540 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 2080P0202X | A109143 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 2080P0202X | MD2021-0101 | NM | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 000000645226 | 01 | OH | ANTHEM | OTHER | 9766413 | 01 | OH | AETNA | OTHER | 3007356 | 05 | OH | MEDICAID | 3007356 | 01 | OH | BCMH | OTHER | 05930 | 01 | OH | PARAMOUNT | OTHER |