Provider Demographics
NPI:1013417294
Name:MEHRA, NADER
Entity Type:Individual
Prefix:
First Name:NADER
Middle Name:
Last Name:MEHRA
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 1:2152 DANBERRY LN
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-1258
Mailing Address - Country:US
Mailing Address - Phone:415-497-2067
Mailing Address - Fax:
Practice Address - Street 1:4515 FERMI PL STE 106
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95618-9411
Practice Address - Country:US
Practice Address - Phone:530-750-1955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA104292122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program