Basic Information
Provider Information | |||||||||
NPI: | 1669646170 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VERA | ||||||||
FirstName: | ZAKA | ||||||||
MiddleName: | UDDIN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | VERA | ||||||||
OtherFirstName: | ZAKA | ||||||||
OtherMiddleName: | UDDIN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 200 OCEANGATE | ||||||||
Address2: | SUITE 100 | ||||||||
City: | LONG BEACH | ||||||||
State: | CA | ||||||||
PostalCode: | 908024302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9163991100 | ||||||||
FaxNumber: | 8778602397 | ||||||||
Practice Location | |||||||||
Address1: | 7215 55TH STREET | ||||||||
Address2: |   | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958232601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9163991100 | ||||||||
FaxNumber: | 8778602397 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/15/2008 | ||||||||
LastUpdateDate: | 04/15/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | AFE25256 | CA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | A25256 | CA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | P01222618/ DS9933 | 01 | CA | RAILROAD MEDICARE-CITRUS HEIGHTS, 55TH ST. | OTHER | 1669646170 | 05 | CA |   | MEDICAID | 1669646170 | 01 | CA | MEDI-CAL | OTHER |