1013083179 NPI number — MEHRDAD JAFARZADEH MD

Table of content: MEHRDAD JAFARZADEH MD (NPI 1013083179)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013083179 NPI number — MEHRDAD JAFARZADEH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JAFARZADEH
Provider First Name:
MEHRDAD
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:
JAFARZADEH-KHOSRARI
Provider Other First Name:
MEHRDAD
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1013083179
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3400 DATA DRIVE
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:
916-564-3040
Provider Business Mailing Address Fax Number:
916-564-3065

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6401 COYLE AVE STE 416
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-966-3501
Provider Business Practice Location Address Fax Number:
916-966-2805
Provider Enumeration Date:
11/28/2006

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: 207RC0000X , with the licence number:  A66815 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RI0011X , with the licence number: A66815 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207UN0901X , with the licence number: A66815 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 00A668150 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0068233 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR006823B , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0068230 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0068232 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ47674Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ47676Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0068235 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ47673Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 060068134 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ62306Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0068231 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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