=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124218979
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WATT AVENUE MEDICAL CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2007
-----------------------------------------------------
Last Update Date | 12/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5710 WATT AVE
-----------------------------------------------------
City | NORTH HIGHLANDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95660-4752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-344-8866
-----------------------------------------------------
Fax | 916-344-3979
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5710 WATT AVE
-----------------------------------------------------
City | NORTH HIGHLANDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95660-4752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-344-8866
-----------------------------------------------------
Fax | 916-344-3979
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. NOUROLLAH DANIALYPOUR
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 916-344-8866
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | A41114
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------