Provider Demographics
NPI:1194953901
Name:BAKHTAR, OMID (DO)
Entity type:Individual
Prefix:DR
First Name:OMID
Middle Name:
Last Name:BAKHTAR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3035 DUVALL CT
Mailing Address - Street 2:
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-9165
Mailing Address - Country:US
Mailing Address - Phone:517-604-0274
Mailing Address - Fax:
Practice Address - Street 1:65 NEILSON ST STE 102
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-2491
Practice Address - Country:US
Practice Address - Phone:831-768-6217
Practice Address - Fax:831-768-6219
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101018220207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine