Healthcare Provider Details

I. General information

NPI: 1790757441
Provider Name (Legal Business Name): ABOLGHASEM ABDOLI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 S BASCOM AVE PEDIATRICS DEPT
SAN JOSE CA
95128-2604
US

IV. Provider business mailing address

751 S BASCOM AVE PEDIATRICS
SAN JOSE CA
95128-2604
US

V. Phone/Fax

Practice location:
  • Phone: 408-885-6616
  • Fax:
Mailing address:
  • Phone: 408-885-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA49572
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberA49572
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: