Healthcare Provider Details

I. General information

NPI: 1114151719
Provider Name (Legal Business Name): ALI MEHDIZADEH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2009
Last Update Date: 04/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11234 ANDERSON ST HOUSE STAFF OFFICE CP 21005
LOMA LINDA CA
92354-2804
US

IV. Provider business mailing address

11234 ANDERSON ST HOUSE STAFF OFFICE CP 21005
LOMA LINDA CA
92345-2804
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-8131
  • Fax: 909-558-0430
Mailing address:
  • Phone: 909-558-8131
  • Fax: 909-558-0430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License NumberA113137
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: