Healthcare Provider Details

I. General information

NPI: 1538655279
Provider Name (Legal Business Name): SAHAB KEVIN DANESH DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2018
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3569 ROUND BARN CIR
SANTA ROSA CA
95403-5781
US

IV. Provider business mailing address

3569 ROUND BARN CIR
SANTA ROSA CA
95403-5781
US

V. Phone/Fax

Practice location:
  • Phone: 707-303-3600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE5837
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE5837
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberE5837
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: