Healthcare Provider Details

I. General information

NPI: 1194134049
Provider Name (Legal Business Name): ABBAS MAHDAVI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2014
Last Update Date: 08/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 LONE TREE WAY # 3
ANTIOCH CA
94509-6018
US

IV. Provider business mailing address

3700 LONE TREE WAY # 3
ANTIOCH CA
94509-6018
US

V. Phone/Fax

Practice location:
  • Phone: 925-754-7200
  • Fax:
Mailing address:
  • Phone: 925-754-7200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA31325
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: