Healthcare Provider Details

I. General information

NPI: 1275514986
Provider Name (Legal Business Name): BEHZAD TAGHIZADEH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 01/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 RESERVOIR DR STE 209
SAN DIEGO CA
92120-5186
US

IV. Provider business mailing address

5555 RESERVOIR DR STE 209
SAN DIEGO CA
92120-5186
US

V. Phone/Fax

Practice location:
  • Phone: 336-414-6079
  • Fax: 858-771-1534
Mailing address:
  • Phone: 336-414-6079
  • Fax: 858-771-1534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number200300293
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number0101232582
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberC58208
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: