Healthcare Provider Details

I. General information

NPI: 1245542125
Provider Name (Legal Business Name): BAHMAN PANBEHI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2010
Last Update Date: 07/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 S MAIN ST PEDIATRIC RESIDENCY OFFICE
ORANGE CA
92868-3835
US

IV. Provider business mailing address

455 S MAIN ST PEDIATRIC RESIDENCY OFFICE
ORANGE CA
92868-3835
US

V. Phone/Fax

Practice location:
  • Phone: 608-630-0210
  • Fax:
Mailing address:
  • Phone: 608-630-0210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA111751
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: