Healthcare Provider Details

I. General information

NPI: 1508970682
Provider Name (Legal Business Name): NOUROLLAH B. GHORBANI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 04/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 LA CASA VIA STE 102
WALNUT CREEK CA
94598-3025
US

IV. Provider business mailing address

130 LA CASA VIA STE 102
WALNUT CREEK CA
94598-3025
US

V. Phone/Fax

Practice location:
  • Phone: 925-946-9004
  • Fax: 925-946-9319
Mailing address:
  • Phone: 925-946-9004
  • Fax: 925-946-9319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA40690
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: