Provider Demographics
NPI:1316459050
Name:ADLTABATABAIE, FARDAD
Entity type:Individual
Prefix:
First Name:FARDAD
Middle Name:
Last Name:ADLTABATABAIE
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 1:15 ACACIA TREE LN
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-2201
Mailing Address - Country:US
Mailing Address - Phone:650-746-4445
Mailing Address - Fax:
Practice Address - Street 1:15 ACACIA TREE LN
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-2201
Practice Address - Country:US
Practice Address - Phone:650-746-4445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-03
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies