Healthcare Provider Details

I. General information

NPI: 1295002079
Provider Name (Legal Business Name): NEELUFAR GHADERI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2011
Last Update Date: 03/05/2021
Certification Date: 03/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 MILVIA ST
BERKELEY CA
94704-2636
US

IV. Provider business mailing address

325 DISTEL CIR
LOS ALTOS CA
94022-1408
US

V. Phone/Fax

Practice location:
  • Phone: 510-204-5600
  • Fax: 510-506-7722
Mailing address:
  • Phone: 510-506-7722
  • Fax: 510-506-7722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1004796
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierA116807
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerSTATE MEDICAL LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: