=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689512055
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AHMAD MAWLAVIZADA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2026
-----------------------------------------------------
Last Update Date | 03/24/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 31268 SANTA CATALINA WAY
-----------------------------------------------------
City | UNION CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94587-2841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-857-6778
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31268 SANTA CATALINA WAY
-----------------------------------------------------
City | UNION CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94587-2841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-857-6778
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 242T00000X
-----------------------------------------------------
Taxonomy Name | Perfusionist
-----------------------------------------------------
License Number | 249158
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------