Provider Demographics
NPI:1194559559
Name:BAKHTIAR, BRANDON
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:BAKHTIAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 MARINERS ISLAND BLVD APT 6
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94404-1022
Mailing Address - Country:US
Mailing Address - Phone:916-812-4190
Mailing Address - Fax:
Practice Address - Street 1:2401 E 3RD AVE
Practice Address - Street 2:
Practice Address - City:FOSTER CITY
Practice Address - State:CA
Practice Address - Zip Code:94404-1067
Practice Address - Country:US
Practice Address - Phone:916-812-4190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist