Provider Demographics
NPI:1104071885
Name:MEHDI, JAANEALI (MD)
Entity type:Individual
Prefix:DR
First Name:JAANEALI
Middle Name:
Last Name:MEHDI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 STANDIFORD AVE STE F
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-1159
Mailing Address - Country:US
Mailing Address - Phone:209-579-5628
Mailing Address - Fax:
Practice Address - Street 1:1501 CLAUS RD STE F
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-9711
Practice Address - Country:US
Practice Address - Phone:095-576-3102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-23
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC1565592084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK053440Medicare PIN
KYK053441Medicare PIN