Healthcare Provider Details

I. General information

NPI: 1992751440
Provider Name (Legal Business Name): BABAK ROSHDIEH, M.D. CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 09/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 MAGNOLIA AVE SUITE 2G
CORONA CA
92879-3120
US

IV. Provider business mailing address

770 MAGNOLIA AVE SUITE 2G
CORONA CA
92879-3120
US

V. Phone/Fax

Practice location:
  • Phone: 951-734-6500
  • Fax: 951-734-6555
Mailing address:
  • Phone: 951-734-6500
  • Fax: 951-734-6555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA76333
License Number StateCA

VIII. Authorized Official

Name: BABAK ROSHDIEH
Title or Position: OWNER
Credential: M.D.
Phone: 951-734-6500