Healthcare Provider Details

I. General information

NPI: 1164470639
Provider Name (Legal Business Name): GHOLAMREZA VAFADOUSTE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 04/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2141 COLORADO AVE
TURLOCK CA
95382-2011
US

IV. Provider business mailing address

PO BOX 4398
MODESTO CA
95352-4398
US

V. Phone/Fax

Practice location:
  • Phone: 209-575-4575
  • Fax: 209-575-4598
Mailing address:
  • Phone: 209-575-4575
  • Fax: 209-575-4598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberA79905
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: