Basic Information
| Provider Information | |||||||||
| NPI: | 1679558605 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JAVIDAN-NEJAD | ||||||||
| FirstName: | JAVID | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 DATA DRIVE | ||||||||
| Address2: | CREDENTIALING DEPARTMENT | ||||||||
| City: | RANCHO GORDOVA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956707956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167345154 | ||||||||
| FaxNumber: | 9167348094 | ||||||||
| Practice Location | |||||||||
| Address1: | 6620 COYLE AVENUE | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | CARMICHAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956086337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169612514 | ||||||||
| FaxNumber: | 9169611182 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2005 | ||||||||
| LastUpdateDate: | 12/20/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | A83658 | CA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 00A836580 | 05 | CA | MEDICAID |