1144331224 NPI number — MEHRDAD AMIRHAMZEH, M.D., INC.

Table of content: (NPI 1144331224)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144331224 NPI number — MEHRDAD AMIRHAMZEH, M.D., INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEHRDAD AMIRHAMZEH, M.D., INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1144331224
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1610 W YOSEMITE AVE
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
MANTECA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95337-5189
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-665-4412
Provider Business Mailing Address Fax Number:
209-665-4415

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1610 W YOSEMITE AVE
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
MANTECA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95337-5189
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-665-4412
Provider Business Practice Location Address Fax Number:
209-665-4415
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
AMIRHAMZEH
Authorized Official First Name:
MEHRDAD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
209-665-4412

Provider Taxonomy Codes

  • Taxonomy code: 208G00000X , with the licence number:  G86572 , 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: 00G865720 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ03769Z . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".




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