Provider Demographics
NPI:1588774707
Name:KANGARLU, SOPHIA SAEEDIAN (MD)
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:SAEEDIAN
Last Name:KANGARLU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NARGES
Other - Middle Name:SAEEDIAN
Other - Last Name:MAZJ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7969 N BLACKSTONE AVE # 176
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-4310
Mailing Address - Country:US
Mailing Address - Phone:559-312-8300
Mailing Address - Fax:559-298-7259
Practice Address - Street 1:7969 N BLACKSTONE AVE # 176
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-4310
Practice Address - Country:US
Practice Address - Phone:559-312-8300
Practice Address - Fax:559-298-7259
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA74483207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA74483Medicaid
CACU080ZMedicare UPIN
CAA74483Medicaid