Provider Demographics
NPI:1316973605
Name:HASANIYA, NAHIDH W (MDPHD)
Entity type:Individual
Prefix:
First Name:NAHIDH
Middle Name:W
Last Name:HASANIYA
Suffix:
Gender:M
Credentials:MDPHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:ATTN: CREDENTIALING/PAYER ENROLLMENT
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 E HIGHLAND AVE STE 251
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3800
Practice Address - Country:US
Practice Address - Phone:909-882-4605
Practice Address - Fax:909-475-2680
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51994208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A519940Medicaid
CA00A519940Medicaid
G38983Medicare UPIN
CA00A519942Medicare PIN