MEDICARE: CALIFORNIA KIDNEY DISEASE ASSOCIATES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	A121191	CA
2	207RN0300X	Nephrology Physician	A121191	CA

General Provider Information

NPI Number	:	1194242313
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CALIFORNIA KIDNEY DISEASE ASSOCIATES

Provider Business Mailing Address
First Line	:	PO BOX 980934
Second Line	:
City	:	W SACRAMENTO
State	:	CA
Zip	:	95798-0934
Country	:	US
Telephone Number	:	916-500-4706
Fax Number	:	916-200-4999

Provider Business Practice Location Address
First Line	:	1736 PROFESSIONAL DR
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95825-2105
Country	:	US
Telephone Number	:	916-500-4706
Fax Number	:	916-200-4999

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ABDUL NURISTANI
Credential	:	MD
Telephone Number	:	916-500-4706

Provider Enumeration Date	:	08/28/2017
Last Update Date	:	06/13/2023

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