1467714782 NPI number — DR. ABDUL MALIK DREDAR MD

Table of content: DR. ABDUL MALIK DREDAR MD (NPI 1467714782)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467714782 NPI number — DR. ABDUL MALIK DREDAR MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DREDAR
Provider First Name:
ABDUL MALIK
Provider Middle Name:
Provider Name Prefix Text:
DR.
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:
1467714782
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3400 DATA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RANCHO CORDOVA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95670-7956
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6511 COYLE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARMICHAEL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95608-0306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-863-8700
Provider Business Practice Location Address Fax Number:
916-961-9016
Provider Enumeration Date:
06/12/2012

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: 2085R0202X , with the licence number:  MD60754557 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: A133687 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: A133687 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1467714782 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".