1518192038 NPI number — REZA VAFADOUSTE MD A MEDICAL CORPORATION

Table of content: (NPI 1518192038)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518192038 NPI number — REZA VAFADOUSTE MD A MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REZA VAFADOUSTE MD A MEDICAL CORPORATION
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:
6
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:
1518192038
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4398
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MODESTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95352-4398
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-575-4575
Provider Business Mailing Address Fax Number:
209-529-3260

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
850 W OLIVE AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MERCED
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95348-2427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-725-1990
Provider Business Practice Location Address Fax Number:
209-529-3260
Provider Enumeration Date:
05/28/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ADAMS
Authorized Official First Name:
JUNE
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
209-575-4575

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  A79905 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RP1001X , with the licence number: A100098 , 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)





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