MEDICARE: BAHRAM BAHRAMI

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	174400000X	Specialist	A-23638	CA

General Provider Information

NPI Number	:	1225188089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BAHRAM BAHRAMI

Provider Business Mailing Address
First Line	:	777 BANGOR ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92106-2951
Country	:	US
Telephone Number	:	619-857-0063
Fax Number	:	760-480-4350

Provider Business Practice Location Address
First Line	:	2934 INGELOW ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92106-2311
Country	:	US
Telephone Number	:	760-480-4310
Fax Number	:	760-480-4350

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	11/18/2015

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