Healthcare Provider Details

I. General information

NPI: 1194864769
Provider Name (Legal Business Name): REZA VAFADOUSTE MD A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
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: 209-634-2600
  • 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
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA79905
License Number StateCA

VIII. Authorized Official

Name: DR. REZA VAFADOUSTE
Title or Position: PRESIDENT
Credential: MD
Phone: 209-575-4575