Provider Demographics
NPI:1194864769
Name:REZA VAFADOUSTE MD A MEDICAL CORPORATION
Entity type:Organization
Organization Name:REZA VAFADOUSTE MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REZA
Authorized Official - Middle Name:
Authorized Official - Last Name:VAFADOUSTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-575-4575
Mailing Address - Street 1:PO BOX 4398
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95352-4398
Mailing Address - Country:US
Mailing Address - Phone:209-575-4575
Mailing Address - Fax:209-575-4598
Practice Address - Street 1:2141 COLORADO AVE
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-2011
Practice Address - Country:US
Practice Address - Phone:209-634-2600
Practice Address - Fax:209-575-4598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79905207RC0000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A799050Medicaid
CAZZZ27290ZMedicare PIN
CAH12284Medicare UPIN