Provider Demographics
NPI:1285963124
Name:FARIBORZ LALEZARZADEH DO INC
Entity type:Organization
Organization Name:FARIBORZ LALEZARZADEH DO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FARIBORZ
Authorized Official - Middle Name:
Authorized Official - Last Name:LALEZARZADEH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:909-883-8834
Mailing Address - Street 1:700 E REDLANDS BLVD STE U506
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-6109
Mailing Address - Country:US
Mailing Address - Phone:909-883-8834
Mailing Address - Fax:909-883-8834
Practice Address - Street 1:164 W HOSPITALITY LN STE 100
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3316
Practice Address - Country:US
Practice Address - Phone:909-883-8834
Practice Address - Fax:909-644-4021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-23
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208600000X
CA20A8309261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA020A83090Medicaid
CA020A83090Medicaid