Healthcare Provider Details

I. General information

NPI: 1598821589
Provider Name (Legal Business Name): OMID REZA BAKHTAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ARBOR DR MB#8720
SAN DIEGO CA
92103-8720
US

IV. Provider business mailing address

200 W ARBOR DR MB#8720
SAN DIEGO CA
92103-8720
US

V. Phone/Fax

Practice location:
  • Phone: 619-543-5966
  • Fax: 619-543-3730
Mailing address:
  • Phone: 619-543-5966
  • Fax: 619-543-3730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberA86149
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: