=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841409612
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DANESH MEDICAL OFFICE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 CREEKSIDE DR SUITE 3600
-----------------------------------------------------
City | FOLSOM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95630-3444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-984-6100
-----------------------------------------------------
Fax | 916-984-6129
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1600 CREEKSIDE DR STE 3600
-----------------------------------------------------
City | FOLSOM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95630-3446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-984-6100
-----------------------------------------------------
Fax | 916-984-6129
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. WALI A DANESH
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 916-984-6100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | A75706
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------