Healthcare Provider Details

I. General information

NPI: 1972602464
Provider Name (Legal Business Name): MIKE M HEYDARI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2460 MISSION ST STE 208
SAN FRANCISCO CA
94110-2476
US

IV. Provider business mailing address

1644 ALUM ROCK AVE
SAN JOSE CA
95116-2429
US

V. Phone/Fax

Practice location:
  • Phone: 408-347-1680
  • Fax: 408-347-1681
Mailing address:
  • Phone: 408-347-1680
  • Fax: 408-347-1681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA40606
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: