Provider Demographics
NPI:1417345091
Name:BTLA VI
Entity type:Organization
Organization Name:BTLA VI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BEHZAD
Authorized Official - Middle Name:
Authorized Official - Last Name:TAGHIZADEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-414-6079
Mailing Address - Street 1:5555 RESERVOIR DR
Mailing Address - Street 2:SUITE #209
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-5134
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5555 RESERVOIR DR
Practice Address - Street 2:SUITE #209
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5134
Practice Address - Country:US
Practice Address - Phone:336-414-6079
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC58208207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1275514986Medicaid
CA1275514986Medicare UPIN
CA1275514986Medicare PIN