Healthcare Provider Details

I. General information

NPI: 1114184587
Provider Name (Legal Business Name): ALI HALLAJ-POUR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ALIREZA HALLADGPOUR MD

II. Dates (important events)

Enumeration Date: 05/21/2008
Last Update Date: 05/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2191 MOWRY AVE STE 600C
FREMONT CA
94538-1702
US

IV. Provider business mailing address

2191 MOWRY AVE STE 600C
FREMONT CA
94538-1702
US

V. Phone/Fax

Practice location:
  • Phone: 510-792-4373
  • Fax:
Mailing address:
  • Phone: 510-792-4373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA103981
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: