=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164470639
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GHOLAMREZA VAFADOUSTE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2006
-----------------------------------------------------
Last Update Date | 04/16/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2141 COLORADO AVE
-----------------------------------------------------
City | TURLOCK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95382-2011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-575-4575
-----------------------------------------------------
Fax | 209-575-4598
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4398
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95352-4398
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-575-4575
-----------------------------------------------------
Fax | 209-575-4598
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | A79905
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------