Healthcare Provider Details

I. General information

NPI: 1447835459
Provider Name (Legal Business Name): EIDEN BABAOGHLI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2021
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7002 HOLLOW LAKE WAY
SAN JOSE CA
95120-5811
US

IV. Provider business mailing address

7002 HOLLOW LAKE WAY
SAN JOSE CA
95120-5811
US

V. Phone/Fax

Practice location:
  • Phone: 408-431-2939
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: