Basic Information
| Provider Information | |||||||||
| NPI: | 1194864769 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REZA VAFADOUSTE MD A MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4398 | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953524398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095754575 | ||||||||
| FaxNumber: | 2095754598 | ||||||||
| Practice Location | |||||||||
| Address1: | 2141 COLORADO AVE | ||||||||
| Address2: | |||||||||
| City: | TURLOCK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953822011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2096342600 | ||||||||
| FaxNumber: | 2095754598 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2007 | ||||||||
| LastUpdateDate: | 04/16/2010 | ||||||||
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| AuthorizedOfficialLastName: | VAFADOUSTE | ||||||||
| AuthorizedOfficialFirstName: | REZA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2095754575 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | A79905 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RC0000X | A79905 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 00A799050 | 05 | CA | MEDICAID |