Healthcare Provider Details

I. General information

NPI: 1316250376
Provider Name (Legal Business Name): MEHDI KOOLAEE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2010
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 THORNTON WAY
SAN JOSE CA
95128-4702
US

IV. Provider business mailing address

850 THORNTON WAY
SAN JOSE CA
95128-4702
US

V. Phone/Fax

Practice location:
  • Phone: 408-793-1900
  • Fax:
Mailing address:
  • Phone: 408-793-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License Number142664
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: