Healthcare Provider Details

I. General information

NPI: 1518192038
Provider Name (Legal Business Name): REZA VAFADOUSTE MD A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2009
Last Update Date: 07/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 W OLIVE AVE SUITE A
MERCED CA
95348-2427
US

IV. Provider business mailing address

PO BOX 4398
MODESTO CA
95352-4398
US

V. Phone/Fax

Practice location:
  • Phone: 209-725-1990
  • Fax: 209-529-3260
Mailing address:
  • Phone: 209-575-4575
  • Fax: 209-529-3260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberA79905
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA100098
License Number StateCA

VIII. Authorized Official

Name: MS. JUNE ADAMS
Title or Position: OFFICE MANAGER
Credential:
Phone: 209-575-4575