Healthcare Provider Details

I. General information

NPI: 1700571072
Provider Name (Legal Business Name): SEYEDE TANNAZ EGHBALI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2023
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4371 LATHAM ST
RIVERSIDE CA
92501-1706
US

IV. Provider business mailing address

4371 LATHAM ST
RIVERSIDE CA
92501-1706
US

V. Phone/Fax

Practice location:
  • Phone: 833-867-4642
  • Fax: 360-462-2757
Mailing address:
  • Phone: 833-867-4642
  • Fax: 360-462-2757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA203833
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: