Healthcare Provider Details

I. General information

NPI: 1700888690
Provider Name (Legal Business Name): VINCE FERHAD AFSAHI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 03/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2552 WALNUT AVE SUITE 120
TUSTIN CA
92780-6935
US

IV. Provider business mailing address

2552 WALNUT AVE SUITE 120
TUSTIN CA
92780-6935
US

V. Phone/Fax

Practice location:
  • Phone: 714-508-0754
  • Fax: 174-508-5754
Mailing address:
  • Phone: 714-508-0754
  • Fax: 174-508-5754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA67614
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberA67614
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: