Healthcare Provider Details

I. General information

NPI: 1336383652
Provider Name (Legal Business Name): KIAN MOSTAFAVI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2009
Last Update Date: 12/15/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 MERCED ST
SAN LEANDRO CA
94577-4201
US

IV. Provider business mailing address

2500 MERCED ST
SAN LEANDRO CA
94577-4201
US

V. Phone/Fax

Practice location:
  • Phone: 510-454-1000
  • Fax: 937-208-4286
Mailing address:
  • Phone: 510-454-1000
  • Fax: 937-208-4286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberA120688
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: