Basic Information
| Provider Information | |||||||||
| NPI: | 1154461051 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAZYANI | ||||||||
| FirstName: | MENOUCHEHR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30195 FRASER DR | ||||||||
| Address2: | |||||||||
| City: | LAKE ELSINORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925307006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512522720 | ||||||||
| FaxNumber: | 7604143892 | ||||||||
| Practice Location | |||||||||
| Address1: | 2497 HERNDON AVE | ||||||||
| Address2: | |||||||||
| City: | CLOVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936118976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004924227 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0204X | A87582 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | 208000000X | A87582 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 00A875820 | 05 | CA | MEDICAID |