Healthcare Provider Details

I. General information

NPI: 1164593802
Provider Name (Legal Business Name): DARYOUSH JADALI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 LYNN RD SUITE 125
THOUSAND OAKS CA
91360-1935
US

IV. Provider business mailing address

PO BOX 7448
THOUSAND OAKS CA
91359-7448
US

V. Phone/Fax

Practice location:
  • Phone: 805-777-7406
  • Fax: 805-554-4583
Mailing address:
  • Phone: 805-643-9781
  • Fax: 800-564-3878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License NumberA48921
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: