Healthcare Provider Details

I. General information

NPI: 1285963124
Provider Name (Legal Business Name): FARIBORZ LALEZARZADEH DO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2009
Last Update Date: 11/08/2022
Certification Date: 11/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 W HOSPITALITY LN STE 100
SAN BERNARDINO CA
92408-3316
US

IV. Provider business mailing address

700 E REDLANDS BLVD STE U506
REDLANDS CA
92373-6109
US

V. Phone/Fax

Practice location:
  • Phone: 909-883-8834
  • Fax: 909-644-4021
Mailing address:
  • Phone: 909-883-8834
  • Fax: 909-883-8834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number20A8309
License Number StateCA

VIII. Authorized Official

Name: FARIBORZ LALEZARZADEH
Title or Position: PRESIDENT
Credential: DO
Phone: 909-883-8834