Healthcare Provider Details

I. General information

NPI: 1316685241
Provider Name (Legal Business Name): SIAVASH MEHDIZADEH SERAJ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2022
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W HOSPITAL RD
FRENCH CAMP CA
95231-9693
US

IV. Provider business mailing address

PO BOX 1020
STOCKTON CA
95201-3120
US

V. Phone/Fax

Practice location:
  • Phone: 209-468-6032
  • Fax:
Mailing address:
  • Phone: 209-468-6032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA198397
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberA198397
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: