Provider Demographics
NPI:1720124779
Name:DADGOSTAR, BAHMAN
Entity type:Individual
Prefix:MR
First Name:BAHMAN
Middle Name:
Last Name:DADGOSTAR
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 1:11171 OAKWOOD DR
Mailing Address - Street 2:# E-105
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-4802
Mailing Address - Country:US
Mailing Address - Phone:909-799-7951
Mailing Address - Fax:
Practice Address - Street 1:700 E GILBERT ST
Practice Address - Street 2:COTTAGE 4 ACCESS
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-1003
Practice Address - Country:US
Practice Address - Phone:909-381-2420
Practice Address - Fax:909-386-0770
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health