Basic Information
| Provider Information | |||||||||
| NPI: | 1295002079 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GHADERI | ||||||||
| FirstName: | NEELUFAR | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 325 DISTEL CIR | ||||||||
| Address2: | |||||||||
| City: | LOS ALTOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940221408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105067722 | ||||||||
| FaxNumber: | 5105067722 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 MILVIA ST | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947042636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102045600 | ||||||||
| FaxNumber: | 5105067722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2011 | ||||||||
| LastUpdateDate: | 03/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 1004796 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | A116807 | 01 | CA | STATE MEDICAL LICENSE | OTHER |